Provider Demographics
NPI:1376582940
Name:BURNHAM, VICKI J (ARNP)
Entity Type:Individual
Prefix:MISS
First Name:VICKI
Middle Name:J
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11040 FORT KING RD
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-8554
Mailing Address - Country:US
Mailing Address - Phone:352-567-1339
Mailing Address - Fax:
Practice Address - Street 1:600 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5925
Practice Address - Country:US
Practice Address - Phone:352-323-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9188221363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304948500Medicaid
FL304948500Medicaid
FLE8492UMedicare PIN
FLE8492VMedicare PIN
FLE8492YMedicare ID - Type Unspecified