Healthcare Provider Details

I. General information

NPI: 1780315549
Provider Name (Legal Business Name): REBECCA BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 07/02/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4471 BANNER MOUNTAIN RD
SHIRLEY AR
72153-8428
US

IV. Provider business mailing address

4471 BANNER MOUNTAIN RD
SHIRLEY AR
72153-8428
US

V. Phone/Fax

Practice location:
  • Phone: 501-253-0043
  • Fax:
Mailing address:
  • Phone: 501-253-0043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: