Healthcare Provider Details

I. General information

NPI: 1326889379
Provider Name (Legal Business Name): LISA MARIE BURKHART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6571 AFTER HOURS RD
BRULE WI
54820
US

IV. Provider business mailing address

9451 E ELM RD
POPLAR WI
54864-9071
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-1173
  • Fax:
Mailing address:
  • Phone: 218-391-8068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number165651-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: