Basic Information
| Provider Information | |||||||||
| NPI: | 1699398529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURNE | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | BUIE | ||||||||
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| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BUIE | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 227 N MAIN ST STE A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273713059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368991571 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2020 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | 85765 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
No ID Information.