Provider Demographics
NPI:1982945069
Name:BURGESS, CORLISTA ANNE (CNM, PHMNP-BC)
Entity Type:Individual
Prefix:
First Name:CORLISTA
Middle Name:ANNE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:CNM, PHMNP-BC
Other - Prefix:
Other - First Name:CORLISTA
Other - Middle Name:ANNE
Other - Last Name:DAMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:2604 E PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23664-1248
Mailing Address - Country:US
Mailing Address - Phone:757-810-2663
Mailing Address - Fax:
Practice Address - Street 1:2604 E PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23664-1248
Practice Address - Country:US
Practice Address - Phone:757-810-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170057176B00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No176B00000XOther Service ProvidersMidwife