Provider Demographics
NPI:1124052568
Name:BOURDON, DINAH S (ANP)
Entity type:Individual
Prefix:
First Name:DINAH
Middle Name:S
Last Name:BOURDON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 BILLINGSLEY RD
Mailing Address - Street 2:STE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1009
Mailing Address - Country:US
Mailing Address - Phone:704-358-2700
Mailing Address - Fax:704-358-2716
Practice Address - Street 1:501 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-358-2700
Practice Address - Fax:704-358-2716
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC151301363LP0808X
NC900130363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124052568Medicaid
NC7005232Medicaid
SCNP1545Medicaid
NC7005232Medicaid
NC1124052568Medicaid
NCNC3506AMedicare PIN
SCNP1545Medicaid