Provider Demographics
NPI:1407872864
Name:BURSLEM, VICTORIA H (CNM)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:H
Last Name:BURSLEM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:VICTORIA
Other - Middle Name:ANN
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1279 HWY 54 WEST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4552
Mailing Address - Country:US
Mailing Address - Phone:770-991-2200
Mailing Address - Fax:770-991-1341
Practice Address - Street 1:1279 HWY 54 WEST
Practice Address - Street 2:SUITE 220
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4552
Practice Address - Country:US
Practice Address - Phone:770-991-2200
Practice Address - Fax:770-991-1341
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN127607367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000696484EMedicaid
CT077450OtherREGISTERED NURSE
CT000288OtherLICENSED NURSE MIDWIFE
CT077450OtherREGISTERED NURSE