Healthcare Provider Details

I. General information

NPI: 1376582940
Provider Name (Legal Business Name): VICKI J BURNHAM ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E DIXIE AVE
LEESBURG FL
34748-5925
US

IV. Provider business mailing address

11040 FORT KING RD
DADE CITY FL
33525-8554
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-5762
  • Fax:
Mailing address:
  • Phone: 352-567-1339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9188221
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: