Provider Demographics
NPI:1013397967
Name:BURNLEY, KATHERINE ANNE (ANP-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANNE
Last Name:BURNLEY
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 VADALABENE DR
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5839
Mailing Address - Country:US
Mailing Address - Phone:618-288-7605
Mailing Address - Fax:618-288-7644
Practice Address - Street 1:2133 VADALABENE DR
Practice Address - Street 2:SUITE 5B
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5839
Practice Address - Country:US
Practice Address - Phone:618-288-7605
Practice Address - Fax:618-288-7644
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014040193363L00000X
IL209012521363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400248973Medicare Oscar/Certification
MOS390000145Medicare Oscar/Certification
ILF400248971Medicare Oscar/Certification
ILF400248972Medicare Oscar/Certification
MO1385530030Medicare Oscar/Certification
MOMA1084014Medicare Oscar/Certification