Provider Demographics
NPI:1336746114
Name:BURSON, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:BURSON
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 1:3421 REBERT PIKE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-9737
Mailing Address - Country:US
Mailing Address - Phone:937-408-5884
Mailing Address - Fax:
Practice Address - Street 1:3421 REBERT PIKE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-9737
Practice Address - Country:US
Practice Address - Phone:937-408-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide