Provider Demographics
NPI:1275781254
Name:BURNHAM, MICHELLE E (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:FNP
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 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2322
Practice Address - Street 1:402 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:MO
Practice Address - Zip Code:63965-0000
Practice Address - Country:US
Practice Address - Phone:573-323-4253
Practice Address - Fax:573-323-4465
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO155361363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275781254Medicaid