Provider Demographics
NPI:1760105613
Name:BURROUGHS, TANAE'JA
Entity Type:Individual
Prefix:
First Name:TANAE'JA
Middle Name:
Last Name:BURROUGHS
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 1:5207 NORMANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-4827
Mailing Address - Country:US
Mailing Address - Phone:904-786-4639
Mailing Address - Fax:
Practice Address - Street 1:5207 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4827
Practice Address - Country:US
Practice Address - Phone:904-786-4639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program