Healthcare Provider Details

I. General information

NPI: 1538663380
Provider Name (Legal Business Name): BONESHA BURWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 STOCKTON ST APT 4156
RICHMOND VA
23224-4351
US

IV. Provider business mailing address

403 STOCKTON ST APT 4156
RICHMOND VA
23224-4351
US

V. Phone/Fax

Practice location:
  • Phone: 804-908-0091
  • Fax:
Mailing address:
  • Phone: 804-908-0091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberT28432454
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: