Provider Demographics
NPI:1790259125
Name:BURGE, REAGAN AMANDA (CNM)
Entity Type:Individual
Prefix:MRS
First Name:REAGAN
Middle Name:AMANDA
Last Name:BURGE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MRS
Other - First Name:REAGAN
Other - Middle Name:AMANDA
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:870 AUSTIN DR STE A
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4585
Practice Address - Country:US
Practice Address - Phone:706-229-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191135367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife