Provider Demographics
NPI:1386299188
Name:BOURQUE, EMILY (RD, LD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 TWIN MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8326
Mailing Address - Country:US
Mailing Address - Phone:337-945-2836
Mailing Address - Fax:
Practice Address - Street 1:123 TWIN MEADOW LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8326
Practice Address - Country:US
Practice Address - Phone:727-201-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8574133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered