Provider Demographics
NPI:1174113344
Name:BOURGON COUDOUX, MATHILDE
Entity type:Individual
Prefix:
First Name:MATHILDE
Middle Name:
Last Name:BOURGON COUDOUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MATHILDE
Other - Middle Name:
Other - Last Name:BOURGON COUDOUX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24962 EL CABALLO ST
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4013
Mailing Address - Country:US
Mailing Address - Phone:424-362-4387
Mailing Address - Fax:
Practice Address - Street 1:24962 EL CABALLO ST
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4013
Practice Address - Country:US
Practice Address - Phone:424-362-4387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula