Healthcare Provider Details

I. General information

NPI: 1508512302
Provider Name (Legal Business Name): AMANDA LORI BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 E LARK ST
GILBERT AZ
85297-4577
US

IV. Provider business mailing address

1422 E LARK ST
GILBERT AZ
85297-4577
US

V. Phone/Fax

Practice location:
  • Phone: 480-603-7380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN144952
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number280404
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: