Provider Demographics
NPI:1164189064
Name:BURGESS, KALEY
Entity Type:Individual
Prefix:
First Name:KALEY
Middle Name:
Last Name:BURGESS
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 1:113 ELWOOD ROY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-2371
Mailing Address - Country:US
Mailing Address - Phone:540-578-0598
Mailing Address - Fax:
Practice Address - Street 1:541 SOUTH COLLEGE AVENUE
Practice Address - Street 2:159 HUMAN PERFORMANCE LAB
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19716
Practice Address - Country:US
Practice Address - Phone:540-578-0598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
DE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer