Provider Demographics
NPI:1639879265
Name:BURGESS, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BURGESS
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 1:16098 STATE ROUTE 217
Mailing Address - Street 2:
Mailing Address - City:SCOTTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45678-9061
Mailing Address - Country:US
Mailing Address - Phone:304-544-0975
Mailing Address - Fax:
Practice Address - Street 1:16098 STATE ROUTE 217
Practice Address - Street 2:
Practice Address - City:SCOTTOWN
Practice Address - State:OH
Practice Address - Zip Code:45678-9061
Practice Address - Country:US
Practice Address - Phone:304-544-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide