Provider Demographics
NPI:1255808754
Name:BURBANK, GINA MARIE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:BURBANK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 ROSELANE ST NW STE 710
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6975
Mailing Address - Country:US
Mailing Address - Phone:678-331-3297
Mailing Address - Fax:678-581-7187
Practice Address - Street 1:6002 PROFESSIONAL PKWY STE 220
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5627
Practice Address - Country:US
Practice Address - Phone:678-715-9690
Practice Address - Fax:678-581-7140
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217757163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1255808754OtherNPI NUMBER