Healthcare Provider Details

I. General information

NPI: 1124633029
Provider Name (Legal Business Name): KANEISHA BURRUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10853 MISTFLOWER WAY
INDIANAPOLIS IN
46235-3563
US

IV. Provider business mailing address

10853 MISTFLOWER WAY
INDIANAPOLIS IN
46235-3563
US

V. Phone/Fax

Practice location:
  • Phone: 317-406-1299
  • Fax:
Mailing address:
  • Phone: 317-406-1299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number20014891
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: