Provider Demographics
NPI:1578075180
Name:BURCH, KEONDRA V
Entity Type:Individual
Prefix:
First Name:KEONDRA
Middle Name:V
Last Name:BURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEONDRA
Other - Middle Name:V
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:797 TEAGUE TRL APT 13207
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3152
Mailing Address - Country:US
Mailing Address - Phone:352-602-5541
Mailing Address - Fax:
Practice Address - Street 1:797 TEAGUE TRL APT 13207
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3152
Practice Address - Country:US
Practice Address - Phone:352-602-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-05
Last Update Date:2017-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care