Healthcare Provider Details

I. General information

NPI: 1477135200
Provider Name (Legal Business Name): STEPHANIE THERESA BURNETT NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 WASHINGTON RD
THOMSON GA
30824-6600
US

IV. Provider business mailing address

PO BOX 925
AUGUSTA GA
30903-0925
US

V. Phone/Fax

Practice location:
  • Phone: 706-595-1411
  • Fax:
Mailing address:
  • Phone: 706-724-8611
  • Fax: 706-724-6202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN167982
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: