Healthcare Provider Details

I. General information

NPI: 1053359943
Provider Name (Legal Business Name): LAWANA MARIE BURTNETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH ST S
FARGO ND
58103-1914
US

IV. Provider business mailing address

510 4TH ST S
FARGO ND
58103-1914
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax:
Mailing address:
  • Phone: 701-318-7841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10531
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: