Provider Demographics
NPI:1790428183
Name:BURNETTE, ROSHELL
Entity Type:Individual
Prefix:
First Name:ROSHELL
Middle Name:
Last Name:BURNETTE
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 1:202 E 91ST ST APT B12
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-1334
Mailing Address - Country:US
Mailing Address - Phone:646-338-5323
Mailing Address - Fax:
Practice Address - Street 1:202 E 91ST ST APT B12
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-1334
Practice Address - Country:US
Practice Address - Phone:646-338-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program