Provider Demographics
NPI:1710585567
Name:BURKETT, LAILYN PINEDA (LMT)
Entity Type:Individual
Prefix:MS
First Name:LAILYN
Middle Name:PINEDA
Last Name:BURKETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 GA HIGHWAY 20 SOUTH
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2877
Mailing Address - Country:US
Mailing Address - Phone:678-607-0640
Mailing Address - Fax:
Practice Address - Street 1:3550 GA HIGHWAY 20 SOUTH
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2877
Practice Address - Country:US
Practice Address - Phone:678-607-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003457225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist