Basic Information
| Provider Information | |||||||||
| NPI: | 1457788390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN BOURGONDIEN | ||||||||
| FirstName: | DOLORES | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH STREET | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3055037363 | ||||||||
| Practice Location | |||||||||
| Address1: | 7481 W OAKLAND PARK BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAUDERHILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333194985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3055037363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2013 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP9239798 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 010140700 | 05 | FL | MEDICAID |