Healthcare Provider Details

I. General information

NPI: 1922338292
Provider Name (Legal Business Name): NATAKI BURKE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10305 MISTY RIDGE DR
JONESBORO GA
30238-8027
US

IV. Provider business mailing address

10305 MISTY RIDGE DR
JONESBORO GA
30238-8027
US

V. Phone/Fax

Practice location:
  • Phone: 617-240-4623
  • Fax:
Mailing address:
  • Phone: 617-240-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMT007621
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT007621
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT007621
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: