Provider Demographics
NPI:1811704091
Name:BURNELL, BEAONCA (LPN)
Entity type:Individual
Prefix:
First Name:BEAONCA
Middle Name:
Last Name:BURNELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 HUMBOLDT PKWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1044
Mailing Address - Country:US
Mailing Address - Phone:716-468-3193
Mailing Address - Fax:
Practice Address - Street 1:299 HUMBOLDT PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1044
Practice Address - Country:US
Practice Address - Phone:716-468-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348992364SL0600X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care