Provider Demographics
NPI:1720351901
Name:BURGESS, SHIRLEY G
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:G
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 1:2349 RENAISSANCE DR
Mailing Address - Street 2:STE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6191
Mailing Address - Country:US
Mailing Address - Phone:702-739-7716
Mailing Address - Fax:
Practice Address - Street 1:2349 RENAISSANCE DR
Practice Address - Street 2:STE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6191
Practice Address - Country:US
Practice Address - Phone:702-739-7716
Practice Address - Fax:702-597-2242
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner