Provider Demographics
NPI:1508442823
Name:BURRIS, NICOLE CHANTE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHANTE
Last Name:BURRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12715 DRIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-4806
Mailing Address - Country:US
Mailing Address - Phone:225-302-2406
Mailing Address - Fax:
Practice Address - Street 1:12628 HOOPER RD STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70818-3527
Practice Address - Country:US
Practice Address - Phone:225-913-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator