Provider Demographics
NPI:1073887659
Name:BURT, KRISTIE L (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:L
Last Name:BURT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:AL
Mailing Address - Zip Code:35983-3737
Mailing Address - Country:US
Mailing Address - Phone:256-526-3323
Mailing Address - Fax:256-526-3324
Practice Address - Street 1:280 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:AL
Practice Address - Zip Code:35983-3737
Practice Address - Country:US
Practice Address - Phone:256-526-3233
Practice Address - Fax:256-526-3324
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191802363L00000X
AL1-123496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121713BMedicaid
AL148530Medicaid
GA102I509766Medicare PIN