Provider Demographics
NPI:1386611911
Name:BOURQUE, JODIE MARIE DUHON (CRNA)
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:MARIE DUHON
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:DUHON
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1103 KALISTE SALOOM RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5783
Mailing Address - Country:US
Mailing Address - Phone:337-988-5646
Mailing Address - Fax:
Practice Address - Street 1:1103 KALISTE SALOOM RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5783
Practice Address - Country:US
Practice Address - Phone:337-988-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07321367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009936312Medicaid
FL307523100Medicaid
FLG3933OtherBLUE CROSS BLUE SHIELD OF
AL591-84925OtherBLUE CROSS BLUE SHIELD OF
FLG3933OtherBLUE CROSS BLUE SHIELD OF