Healthcare Provider Details

I. General information

NPI: 1023580198
Provider Name (Legal Business Name): LAKESHA WILSON BURNELL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAKESHA WILSON BURNELL NP

II. Dates (important events)

Enumeration Date: 12/29/2018
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 7TH ST BLDG 700700A
WARNER ROBINS GA
31098-2227
US

IV. Provider business mailing address

203 LOUDON HILL DR
WARNER ROBINS GA
31088-8531
US

V. Phone/Fax

Practice location:
  • Phone: 478-497-1993
  • Fax:
Mailing address:
  • Phone: 478-550-5789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN148146
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN148146
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: