Provider Demographics
NPI:1356192421
Name:BURDETTE, DEVONTRE STEPHON
Entity type:Individual
Prefix:
First Name:DEVONTRE
Middle Name:STEPHON
Last Name:BURDETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1708
Mailing Address - Country:US
Mailing Address - Phone:662-689-0628
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0002
Practice Address - Country:US
Practice Address - Phone:601-266-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer