Provider Demographics
NPI:1992801393
Name:BOURNE, WANDA HIX
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:HIX
Last Name:BOURNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8809 SW 111TH TER
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-5861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF VETERANS AFFAIRS
Practice Address - Street 2:1601 SW ARCHER ROAD
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4901174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist