Healthcare Provider Details

I. General information

NPI: 1174088058
Provider Name (Legal Business Name): BOBBIE JO BURDETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CORBIN HEIGHTS CIR
GIVEN WV
25245-8072
US

IV. Provider business mailing address

202 CORBIN HEIGHTS CIR
GIVEN WV
25245-8072
US

V. Phone/Fax

Practice location:
  • Phone: 304-532-4463
  • Fax:
Mailing address:
  • Phone: 304-532-4463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN44075NP
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: