Provider Demographics
NPI:1215043757
Name:BURGESS, MARYLOU (NP)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:BURGESS
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:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0284
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:11 HILLS BEACH RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9526
Practice Address - Country:US
Practice Address - Phone:207-602-2358
Practice Address - Fax:207-602-5904
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER024901363LF0000X
MECNP81327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P42135Medicare UPIN
MEP42135Medicare UPIN
NP3516Medicare PIN