Provider Demographics
NPI:1114526233
Name:BURDETTE, KIRSTIN DENISE
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:DENISE
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRSTIN
Other - Middle Name:DENISE
Other - Last Name:HYPES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1235
Mailing Address - Country:US
Mailing Address - Phone:304-453-2800
Mailing Address - Fax:304-453-2820
Practice Address - Street 1:33 ERSKINE LN
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-7842
Practice Address - Country:US
Practice Address - Phone:304-453-2800
Practice Address - Fax:304-453-2820
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024363Medicaid