Healthcare Provider Details

I. General information

NPI: 1245308832
Provider Name (Legal Business Name): NANCY MARIE BURGESS ANPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3617 S PACIFIC HWY
MEDFORD OR
97501-8957
US

IV. Provider business mailing address

3617 S PACIFIC HWY
MEDFORD OR
97501-8957
US

V. Phone/Fax

Practice location:
  • Phone: 541-535-6239
  • Fax: 541-512-1026
Mailing address:
  • Phone: 541-535-6239
  • Fax: 541-512-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number649948
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200750134NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: