Healthcare Provider Details

I. General information

NPI: 1083665491
Provider Name (Legal Business Name): NITASHA LARISMA BURNEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 REDWINE RD SW SUITE 104
ATLANTA GA
30331-5509
US

IV. Provider business mailing address

3885 PRINCETON LAKES WAY SW SUITE 306
ATLANTA GA
30331-5589
US

V. Phone/Fax

Practice location:
  • Phone: 404-629-9495
  • Fax: 404-629-9498
Mailing address:
  • Phone: 404-629-9495
  • Fax: 404-629-9498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number055931
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number055931
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: