Provider Demographics
NPI:1801398896
Name:BOURNE, AMY LUCINDA (RN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LUCINDA
Last Name:BOURNE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 WOLF RD SW
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43837-9227
Mailing Address - Country:US
Mailing Address - Phone:330-204-9715
Mailing Address - Fax:
Practice Address - Street 1:3417 WOLF RD SW
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43837-9227
Practice Address - Country:US
Practice Address - Phone:330-204-9715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.402027163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse