Provider Demographics
NPI:1821778986
Name:BURK, TASOULA CARLY (NP)
Entity Type:Individual
Prefix:
First Name:TASOULA
Middle Name:CARLY
Last Name:BURK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WALNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3124
Mailing Address - Country:US
Mailing Address - Phone:617-592-8349
Mailing Address - Fax:
Practice Address - Street 1:333 ELM ST STE 220
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4530
Practice Address - Country:US
Practice Address - Phone:781-329-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2333839363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care