Provider Demographics
NPI:1265000194
Name:BURGESS, MALEA T (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MALEA
Middle Name:T
Last Name:BURGESS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 STATE HIGHWAY 160
Mailing Address - Street 2:
Mailing Address - City:WARRIOR
Mailing Address - State:AL
Mailing Address - Zip Code:35180-4663
Mailing Address - Country:US
Mailing Address - Phone:205-617-4557
Mailing Address - Fax:
Practice Address - Street 1:5577 CHALKVILLE RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-2171
Practice Address - Country:US
Practice Address - Phone:205-853-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF12200555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine