Provider Demographics
NPI:1801364377
Name:BURKE, ANN MARIE ALICIA (APRN)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:ALICIA
Last Name:BURKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1743 E LINE ST APT 103
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7064
Mailing Address - Country:US
Mailing Address - Phone:850-218-0253
Mailing Address - Fax:
Practice Address - Street 1:215 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5105
Practice Address - Country:US
Practice Address - Phone:352-315-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBURK-AZJWST363LA2200X
FLAPRN9201466363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty