Provider Demographics
NPI:1861939191
Name:BOURNE, COFFEE (CRNA)
Entity type:Individual
Prefix:
First Name:COFFEE
Middle Name:
Last Name:BOURNE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780125
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0125
Mailing Address - Country:US
Mailing Address - Phone:804-922-4844
Mailing Address - Fax:
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5023
Practice Address - Country:US
Practice Address - Phone:804-828-2207
Practice Address - Fax:804-828-8300
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001253399163W00000X
VA0024174431367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse