Provider Demographics
NPI:1598250490
Name:BURNHAM, TIMOTHY BLAKE (FNP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BLAKE
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 FREE GIFT CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-7420
Mailing Address - Country:US
Mailing Address - Phone:478-488-0445
Mailing Address - Fax:
Practice Address - Street 1:1412 PLUNKET RD
Practice Address - Street 2:
Practice Address - City:UNADILLA
Practice Address - State:GA
Practice Address - Zip Code:31091-5600
Practice Address - Country:US
Practice Address - Phone:478-627-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209498363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily