Healthcare Provider Details

I. General information

NPI: 1609464957
Provider Name (Legal Business Name): AVERILL BURGER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 RED OAK DR
CULLODEN WV
25510-9533
US

IV. Provider business mailing address

26 RED OAK DR
CULLODEN WV
25510-9533
US

V. Phone/Fax

Practice location:
  • Phone: 304-690-5110
  • Fax:
Mailing address:
  • Phone: 304-690-5110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11010570
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: