Healthcare Provider Details

I. General information

NPI: 1073444014
Provider Name (Legal Business Name): ALEXIS S BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 LINCOLNWAY W STE T
OSCEOLA IN
46561-2063
US

IV. Provider business mailing address

1415 LINCOLNWAY W STE T
OSCEOLA IN
46561-2063
US

V. Phone/Fax

Practice location:
  • Phone: 574-651-8912
  • Fax: 574-281-4412
Mailing address:
  • Phone: 574-651-8912
  • Fax: 574-281-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: