Provider Demographics
NPI:1851484992
Name:BURR, MARY LOUISE (ANP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:BURR
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SPRING PARK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2386
Mailing Address - Country:US
Mailing Address - Phone:870-424-0053
Mailing Address - Fax:
Practice Address - Street 1:105 SPRING PARK DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2386
Practice Address - Country:US
Practice Address - Phone:870-424-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA001859207Q00000X
ARAO1859363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1851484992Medicaid
AR171117758Medicaid