Healthcare Provider Details

I. General information

NPI: 1396189189
Provider Name (Legal Business Name): MAMIE BURRUSS ND, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 02/25/2023
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W CAPITOL AVE STE 1242
LITTLE ROCK AR
72201-3405
US

IV. Provider business mailing address

425 W CAPITOL AVE STE 1242
LITTLE ROCK AR
72201-3405
US

V. Phone/Fax

Practice location:
  • Phone: 888-376-2643
  • Fax:
Mailing address:
  • Phone: 888-376-2643
  • Fax: 888-376-2643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number099.0134038
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number089
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: