Healthcare Provider Details

I. General information

NPI: 1821778986
Provider Name (Legal Business Name): TASOULA CARLY BURK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 ELM ST STE 220
DEDHAM MA
02026-4530
US

IV. Provider business mailing address

11 WALNUT HILL RD
CHESTNUT HILL MA
02467-3124
US

V. Phone/Fax

Practice location:
  • Phone: 781-329-7311
  • Fax:
Mailing address:
  • Phone: 617-592-8349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN2333839
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: