Kristen Bourque, RD, LD, CLC

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

164.007743 Issued in IL

Practice address

9115 Hague Rd
Indianapolis, IN 46256-1025

Phone

(317) 521-2000

NPI assigned

Jan 16, 2015

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1421366400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1639526400000",
    "number": "1881083699",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7408 W PALATINE AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606311920",
            "telephone_number": "702-250-7901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9115 HAGUE RD",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462561025",
            "telephone_number": "317-521-2000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOURQUE",
        "first_name": "KRISTEN",
        "name_prefix": "Miss",
        "credential": "RD, LD, CLC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-01-16",
        "last_updated": "2021-12-15",
        "certification_date": "2021-12-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "NV",
            "license": "32149DI-0",
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "IL",
            "license": "164.007743",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Bounce Back Physical Therapy
• Bourke Homecare LLC
• Shawn L Bourke, NP
• Matthew Bourne, MS COUNSELING
• Vincent M Bournique, MD
• Alexandria Bousamra-Wright, APRN
• John Steven Bousamra
• Elizabeth Bouse, D.C.
• Amber J Boushehry, MSW, LCSW
• Ross Bastani Boushehry

• Registered Dietitian in Indianapolis, IN
• Providers in Indianapolis, IN by specialty
• Registered Dietitian in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.