Healthcare Provider Details

I. General information

NPI: 1285442657
Provider Name (Legal Business Name): RUSSELL LEE BURNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5148
US

IV. Provider business mailing address

2498 SANDRIDGE RD
GREEN COVE SPRINGS FL
32043-8602
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-8500
  • Fax:
Mailing address:
  • Phone: 904-838-8953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11037366
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: