Provider Demographics
NPI:1003038159
Name:BURGE, BECKY LYNNE
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:LYNNE
Last Name:BURGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DYE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2630
Mailing Address - Country:US
Mailing Address - Phone:740-568-9990
Mailing Address - Fax:
Practice Address - Street 1:963 TICK HILL RD
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:OH
Practice Address - Zip Code:45744-7486
Practice Address - Country:US
Practice Address - Phone:740-350-0863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2409754Medicaid