Healthcare Provider Details

I. General information

NPI: 1790213999
Provider Name (Legal Business Name): TAVIA DANIELLE BURNS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CLINIC DR
MADISONVILLE KY
42431-1661
US

IV. Provider business mailing address

5200 COMMERCE CROSSINGS DR FL 3
LOUISVILLE KY
40229-2182
US

V. Phone/Fax

Practice location:
  • Phone: 270-824-6655
  • Fax: 270-643-4271
Mailing address:
  • Phone: 502-253-4900
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3011340
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: