Provider Demographics
NPI:1073939013
Name:BURNSIDE, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:BURNSIDE
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 1:609 N TOWNVILLE ST
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-2642
Mailing Address - Country:US
Mailing Address - Phone:864-882-2245
Mailing Address - Fax:864-885-9659
Practice Address - Street 1:609 N TOWNVILLE ST
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-2642
Practice Address - Country:US
Practice Address - Phone:864-882-2245
Practice Address - Fax:864-885-9659
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38417P164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse