Provider Demographics
NPI:1720744857
Name:BURTT, JUANITA RENEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:RENEE
Last Name:BURTT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:JUANITA
Other - Middle Name:RENEE
Other - Last Name:BURTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:3419 VIRGINIA BEACH BLVD # 5436
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4419
Mailing Address - Country:US
Mailing Address - Phone:757-374-0869
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1763
Practice Address - Country:US
Practice Address - Phone:757-374-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024283000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty