Provider Demographics
NPI:1720304967
Name:BURNETT, KIMBERLY ODEL (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ODEL
Last Name:BURNETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2059 STATE ROUTE 17C
Mailing Address - Street 2:
Mailing Address - City:BARTON
Mailing Address - State:NY
Mailing Address - Zip Code:13734-1836
Mailing Address - Country:US
Mailing Address - Phone:518-527-0938
Mailing Address - Fax:
Practice Address - Street 1:114 DESMOND ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-2084
Practice Address - Country:US
Practice Address - Phone:570-882-7401
Practice Address - Fax:570-882-7404
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335613363L00000X
PASP010330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400017799Medicare PIN