Provider Demographics
NPI:1154505410
Name:BURRIS, RICKEY JR (NURSE)
Entity Type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:
Last Name:BURRIS
Suffix:JR
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14428 CERISE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-9011
Mailing Address - Country:US
Mailing Address - Phone:310-675-2255
Mailing Address - Fax:
Practice Address - Street 1:14428 CERISE AVE APT 1
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-9011
Practice Address - Country:US
Practice Address - Phone:310-675-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA144237164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse