MEDICARE: AMANDA BURGESS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	205794	SC

General Provider Information

NPI Number	:	1063839132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA BURGESS RN

Provider Business Mailing Address
First Line	:	106 BONHOMME CIR
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-8695
Country	:	US
Telephone Number	:	803-287-1050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1070 S LAKE DR
Second Line	:	SUITE B
City	:	LEXINGTON
State	:	SC
Zip	:	29073-3701
Country	:	US
Telephone Number	:	803-785-6625
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2014
Last Update Date	:	03/26/2014

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