Provider Demographics
NPI:1790242659
Name:BURT, CHARLIE ANN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:ANN
Last Name:BURT
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:ANN
Other - Last Name:ETHRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34793 RICHARD FREY RD
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-5237
Mailing Address - Country:US
Mailing Address - Phone:281-536-0918
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL PLAZA DR STE 250
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3477
Practice Address - Country:US
Practice Address - Phone:281-296-8788
Practice Address - Fax:281-419-1291
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140793363LC0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine