Provider Demographics
NPI:1841449766
Name:BOURNE, LORI K (PA)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:K
Last Name:BOURNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9960 NW 116TH WAY STE 13
Mailing Address - Street 2:
Mailing Address - City:MEDLEY
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1395 N COURTENAY PKWY STE 106
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4474
Practice Address - Country:US
Practice Address - Phone:321-452-1224
Practice Address - Fax:321-453-7784
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2514363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical