Provider Demographics
NPI:1316136864
Name:BOURGOUIN, MICHELE (AP)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BOURGOUIN
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5017
Mailing Address - Country:US
Mailing Address - Phone:844-325-9466
Mailing Address - Fax:
Practice Address - Street 1:1925 HARRISON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-5017
Practice Address - Country:US
Practice Address - Phone:844-325-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2457171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist