Individual
MRS. LYDIA CORNELL BOURKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
2494 S ROCHESTER RD, ROCHESTER HILLS, MI 48307-3817
(248) 299-9850
(248) 299-9860
Mailing address
472 LINCOLN RD, GROSSE POINTE, MI 48230-1609
(248) 299-9850
(248) 299-9860
Taxonomy
Speciality
Code
Description
License number
State
163WM0705X
Medical-Surgical Registered Nurse
4704215985
MI
363LA2200X
Adult Health Nurse Practitioner
Primary
4704215985
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4704215985
NURSE LICENSE
MI
01
—
5008670700
BCBS INDIVIDUAL #
MI
05
—
5187136 10
—
MI
Enumeration date
03/20/2007
Last updated
08/28/2007
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