Healthcare Provider Details

I. General information

NPI: 1740648427
Provider Name (Legal Business Name): KATHRYN BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 DUTCH FORK RD
IRMO SC
29063-8822
US

IV. Provider business mailing address

1020 DUTCH FORK RD
IRMO SC
29063-8822
US

V. Phone/Fax

Practice location:
  • Phone: 803-476-8000
  • Fax:
Mailing address:
  • Phone: 803-476-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number37332
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: