Provider Demographics
NPI:1538140025
Name:BURGESS, MISTI JACKSON (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MISTI
Middle Name:JACKSON
Last Name:BURGESS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MISTI
Other - Middle Name:ALISHA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:749 E VICTOR HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-9230
Mailing Address - Country:US
Mailing Address - Phone:864-591-0992
Mailing Address - Fax:
Practice Address - Street 1:600 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5495
Practice Address - Country:US
Practice Address - Phone:864-591-1839
Practice Address - Fax:864-582-5023
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN 2665363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ49791Medicare UPIN