Healthcare Provider Details

I. General information

NPI: 1427689603
Provider Name (Legal Business Name): KRISTEN POWELL BURDETTE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 ROCKY SLOPE RD
GREENVILLE SC
29607-3909
US

IV. Provider business mailing address

207 ACKERMAN CT
GREENVILLE SC
29607-6419
US

V. Phone/Fax

Practice location:
  • Phone: 864-663-3655
  • Fax:
Mailing address:
  • Phone: 864-567-4348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number23022
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: