| Doctor Name: | MARY BOURBON |
| NPI Number: | 1023499548 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | R089401 |
| Business Practice Address: | 1600 S. Cain Highway Suite 401 Glen Burnie, MD - 21061 |
| Business Phone Number: | 4107685050 |
| Business Fax Number: | |
| Mailing Address: | 1600 S. Cain Highway, Suite 401 GLEN BURNIE |
| State: | MD |
| Postal Code: | 21061 |
| Phone Number: | 4107685050 |
| Fax Number: | |
| NPI Enumeration Date: | 06/10/2015 |
| NPI Last Update Date: | 06/02/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | R089401 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MD |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |