Provider Demographics
NPI:1407582612
Name:BURGOYNE, ADA KATHLEEN (HIS)
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:KATHLEEN
Last Name:BURGOYNE
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 MIDDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-8104
Mailing Address - Country:US
Mailing Address - Phone:304-534-7150
Mailing Address - Fax:304-368-9558
Practice Address - Street 1:162 MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-8104
Practice Address - Country:US
Practice Address - Phone:304-534-7150
Practice Address - Fax:304-368-9558
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1093237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist