Provider Demographics
NPI:1114647039
Name:BOURGETTE, KAYCE JUSTINE (FNP)
Entity type:Individual
Prefix:MS
First Name:KAYCE
Middle Name:JUSTINE
Last Name:BOURGETTE
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:800-647-2098
Mailing Address - Fax:618-622-9724
Practice Address - Street 1:1418 CROSS ST
Practice Address - Street 2:DIV IM MEDICAL ONCOLOGY, STE 180
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2914
Practice Address - Country:US
Practice Address - Phone:800-647-2098
Practice Address - Fax:618-622-9724
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420115728Medicaid