Provider Demographics
NPI:1881083699
Name:BOURQUE, KRISTEN (RD, LD, CLC)
Entity type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:RD, LD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7408 W PALATINE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1920
Mailing Address - Country:US
Mailing Address - Phone:702-250-7901
Mailing Address - Fax:
Practice Address - Street 1:9115 HAGUE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1025
Practice Address - Country:US
Practice Address - Phone:317-521-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV32149DI-0133V00000X
IL164.007743133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV109850Medicare PIN