Provider Demographics
NPI:1558504464
Name:BURNETT, CARLA RILEY
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RILEY
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:RILEY
Other - Last Name:DEVEROEX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:829 RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-1521
Mailing Address - Country:US
Mailing Address - Phone:832-343-8343
Mailing Address - Fax:
Practice Address - Street 1:829 RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-1521
Practice Address - Country:US
Practice Address - Phone:832-343-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging