Provider Demographics
NPI:1417714221
Name:BURGESS, OCTAVIA N (APRN)
Entity Type:Individual
Prefix:MS
First Name:OCTAVIA
Middle Name:N
Last Name:BURGESS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 ADANSON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1317
Mailing Address - Country:US
Mailing Address - Phone:828-390-8255
Mailing Address - Fax:
Practice Address - Street 1:1800 MERCY DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-5646
Practice Address - Country:US
Practice Address - Phone:407-875-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health