Provider Demographics
NPI:1285747642
Name:BOURQUE, KRISTIN ELIZABETH (ATC)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 COLEMAN AVE
Mailing Address - Street 2:MERCER UNIVERSITY ATHLETIC DEPARTMENT
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-0001
Mailing Address - Country:US
Mailing Address - Phone:443-745-3741
Mailing Address - Fax:
Practice Address - Street 1:1400 COLEMAN AVE
Practice Address - Street 2:MERCER UNIVERSITY ATHLETIC DEPARTMENT
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-0001
Practice Address - Country:US
Practice Address - Phone:443-745-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer