Provider Demographics
NPI:1760756126
Name:BURNEY, NATHANIEL LARUE (ATC)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:LARUE
Last Name:BURNEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:MR
Other - First Name:NATHAN
Other - Middle Name:LARUE
Other - Last Name:BURNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:633 EMERSON RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6739
Mailing Address - Country:US
Mailing Address - Phone:785-845-3358
Mailing Address - Fax:
Practice Address - Street 1:633 EMERSON RD
Practice Address - Street 2:SUITE 20
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6739
Practice Address - Country:US
Practice Address - Phone:785-845-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4162255A2300X
MO20140288422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer