Provider Demographics
NPI:1639123318
Name:BURNETT, KATHRYN GAULT (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:GAULT
Last Name:BURNETT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:VIRGINA
Other - Middle Name:KATHRYN
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:29 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2629
Practice Address - Country:US
Practice Address - Phone:864-331-1300
Practice Address - Fax:864-331-1447
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1248363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0408Medicaid
SCP090727951Medicare PIN
SCP09072Medicare UPIN
SCP090727951Medicare PIN