Provider Demographics
NPI:1033752977
Name:BURKE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BURKE
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 1:44973 VOYAGE PATH APT 310
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-2481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22885 DUKE ST
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-3818
Practice Address - Country:US
Practice Address - Phone:301-475-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01997L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist