Healthcare Provider Details

I. General information

NPI: 1770847915
Provider Name (Legal Business Name): CASSONDRA BURKS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S MANUFACTURERS ROW
TRENTON TN
38382-3632
US

IV. Provider business mailing address

72 SMALL OAK DR
HUMBOLDT TN
38343-8644
US

V. Phone/Fax

Practice location:
  • Phone: 731-855-7601
  • Fax: 731-855-7603
Mailing address:
  • Phone: 731-695-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000016699
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: