Healthcare Provider Details

I. General information

NPI: 1629671946
Provider Name (Legal Business Name): TARA NICOLE BURKE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 LEIGHTON AVE
ANNISTON AL
36207-5761
US

IV. Provider business mailing address

731 LEIGHTON AVE
ANNISTON AL
36207-5761
US

V. Phone/Fax

Practice location:
  • Phone: 256-235-5688
  • Fax:
Mailing address:
  • Phone: 256-235-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH9915
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: