Healthcare Provider Details

I. General information

NPI: 1245503572
Provider Name (Legal Business Name): JANELL LESLIE BURGESS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CATON AVE
BALTIMORE MD
21229-5201
US

IV. Provider business mailing address

2411 W BELVEDERE AVE SUITE 206
BALTIMORE MD
21215-5228
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-2414
  • Fax:
Mailing address:
  • Phone: 410-601-8318
  • Fax: 410-601-8576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0004669
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: