Provider Demographics
NPI:1922866110
Name:BURNSIDE, SHIRRELL L
Entity Type:Individual
Prefix:
First Name:SHIRRELL
Middle Name:L
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 1:3475 RED HOOK XING APT E
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6272
Mailing Address - Country:US
Mailing Address - Phone:470-257-3759
Mailing Address - Fax:
Practice Address - Street 1:3475 RED HOOK XING APT E
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6272
Practice Address - Country:US
Practice Address - Phone:147-025-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator