Basic Information
| Provider Information | |||||||||
| NPI: | 1578688560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURKE | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | CORNELL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORNELL | ||||||||
| OtherFirstName: | LYDIA | ||||||||
| OtherMiddleName: | WOOD | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 472 LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482301609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482999850 | ||||||||
| FaxNumber: | 2482999860 | ||||||||
| Practice Location | |||||||||
| Address1: | 2494 S ROCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483073817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482999850 | ||||||||
| FaxNumber: | 2482999860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/28/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 4704215985 | MI | N | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363LA2200X | 4704215985 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 5008670700 | 01 | MI | BCBS INDIVIDUAL # | OTHER | 4704215985 | 01 | MI | NURSE LICENSE | OTHER | 5187136 10 | 05 | MI | MEDICAID | 4704215985 | 01 | MI | NURSE PRACTITIONER LICEN | OTHER |