Provider Demographics
NPI:1235452822
Name:BURNETT, AMANDA VERKRUISSEN (ANP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:VERKRUISSEN
Last Name:BURNETT
Suffix:
Gender:F
Credentials:ANP
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 122205 DEPT 2205
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2205
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:1717 OAK PARK BLVD FL 1
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8977
Practice Address - Country:US
Practice Address - Phone:337-494-6800
Practice Address - Fax:337-494-6761
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP0071363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP0071OtherSTATE MEDICAL LICENSE
LA2102605Medicaid
LA2102605Medicaid