Healthcare Provider Details

I. General information

NPI: 1881469328
Provider Name (Legal Business Name): ANGELA BURGESS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 BAKER ST
BAY AR
72411-9020
US

IV. Provider business mailing address

202 BAKER ST
BAY AR
72411-9020
US

V. Phone/Fax

Practice location:
  • Phone: 870-897-0453
  • Fax:
Mailing address:
  • Phone: 870-897-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number212924
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: