Healthcare Provider Details

I. General information

NPI: 1316836752
Provider Name (Legal Business Name): MADELYN GRACE BURGESS PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 CHARLES T WETHINGTON BUILDING
LEXINGTON KY
40506-0001
US

IV. Provider business mailing address

4015 STONE MILL WAY
CRESTWOOD KY
40014-8761
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-5001
  • Fax:
Mailing address:
  • Phone: 502-438-0361
  • Fax: 502-438-0361

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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: