Provider Demographics
NPI:1609432616
Name:BURGESS, DANA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:MARIE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 GARVER RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-8929
Mailing Address - Country:US
Mailing Address - Phone:513-594-7664
Mailing Address - Fax:
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1983
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.161652.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH164W00000XMedicaid