Provider Demographics
NPI:1275841447
Name:BURKETT, GLENN A
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:A
Last Name:BURKETT
Suffix:
Gender:M
Credentials:
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 9507
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32417-9507
Mailing Address - Country:US
Mailing Address - Phone:850-872-8752
Mailing Address - Fax:850-249-3290
Practice Address - Street 1:5431 AIRPORT PULLING RD N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-2004
Practice Address - Country:US
Practice Address - Phone:239-596-3611
Practice Address - Fax:239-596-6011
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist