Provider Demographics
NPI:1619100484
Name:BURKHOLDER, RITA A (NP)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:A
Last Name:BURKHOLDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-330-3689
Mailing Address - Fax:812-331-3656
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-330-3689
Practice Address - Fax:812-331-3656
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003020A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953470Medicaid
INM400021621Medicare PIN
IN549210VVVVMedicare PIN