Provider Demographics
NPI:1821230087
Name:BURNETT, ANDREA CALLIE (LMT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:CALLIE
Last Name:BURNETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 N OMAHA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4267
Mailing Address - Country:US
Mailing Address - Phone:503-289-4519
Mailing Address - Fax:
Practice Address - Street 1:6125 N OMAHA AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4267
Practice Address - Country:US
Practice Address - Phone:503-289-4519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist