Provider Demographics
NPI:1366645228
Name:BURKHART, MARISA L (LMT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:L
Last Name:BURKHART
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4138
Mailing Address - Country:US
Mailing Address - Phone:407-767-0774
Mailing Address - Fax:
Practice Address - Street 1:285 W PINE AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4138
Practice Address - Country:US
Practice Address - Phone:407-767-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist