Provider Demographics
NPI:1407927155
Name:BURTON, MAE DE ETTE (FNP)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:DE ETTE
Last Name:BURTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SAINT FRANCIS DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-3971
Mailing Address - Country:US
Mailing Address - Phone:864-235-8396
Mailing Address - Fax:864-527-2360
Practice Address - Street 1:3 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 400
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3971
Practice Address - Country:US
Practice Address - Phone:864-235-8396
Practice Address - Fax:864-527-2360
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2534363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA09572039Medicare ID - Type Unspecified
SCP09848Medicare UPIN