Healthcare Provider Details

I. General information

NPI: 1043539273
Provider Name (Legal Business Name): MS. MARY VIRGINIA BURNETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9430 W BRIGHTWAY CIR
RICHMOND VA
23294-5562
US

IV. Provider business mailing address

9430 W BRIGHTWAY CIR
RICHMOND VA
23294-5562
US

V. Phone/Fax

Practice location:
  • Phone: 804-874-3126
  • Fax:
Mailing address:
  • Phone: 804-874-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberA64204782
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: