Provider Demographics
NPI:1699388801
Name:BURGETT, TARA DANIELLE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DANIELLE
Last Name:BURGETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6437 MADDOX RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-6327
Mailing Address - Country:US
Mailing Address - Phone:850-530-2433
Mailing Address - Fax:
Practice Address - Street 1:6437 MADDOX RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-6327
Practice Address - Country:US
Practice Address - Phone:850-530-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty