Provider Demographics
NPI:1932526951
Name:BURSTON, CARRIE DELL
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DELL
Last Name:BURSTON
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 1:3202 E 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-2142
Mailing Address - Country:US
Mailing Address - Phone:813-248-1571
Mailing Address - Fax:
Practice Address - Street 1:3202 E 25TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-2142
Practice Address - Country:US
Practice Address - Phone:813-248-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905194311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home