Provider Demographics
NPI:1477731123
Name:BURNHAM, GRACE ELIZABETH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:ELIZABETH
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 RACE TRACK RD
Mailing Address - Street 2:SUITE 237
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-3239
Mailing Address - Country:US
Mailing Address - Phone:904-287-8306
Mailing Address - Fax:904-287-3413
Practice Address - Street 1:1637 RACE TRACK RD
Practice Address - Street 2:SUITE 237
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-3239
Practice Address - Country:US
Practice Address - Phone:904-287-8306
Practice Address - Fax:904-287-3413
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist