Provider Demographics
NPI:1871254359
Name:BURNSIDE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BURNSIDE
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 1:281 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-3475
Mailing Address - Country:US
Mailing Address - Phone:304-465-3302
Mailing Address - Fax:
Practice Address - Street 1:281 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-3475
Practice Address - Country:US
Practice Address - Phone:304-465-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant