Provider Demographics
NPI:1740736008
Name:BURLESON, KINDAL MAXEY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KINDAL
Middle Name:MAXEY
Last Name:BURLESON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1690 SKYLYN DR STE 300A
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1022
Practice Address - Country:US
Practice Address - Phone:864-342-4000
Practice Address - Fax:864-596-7409
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC94455019OtherMEDICARE PIN