Provider Demographics
NPI:1356816995
Name:BURLESON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BURLESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 COUNTY ROAD 1162
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35057-0641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15445 AL HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-6602
Practice Address - Country:US
Practice Address - Phone:256-974-1597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist