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General NPI Number Information
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NPI Number | 1194914648
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Entity Type | Individual
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Provider Name | NICOLE LYNN BURGESS PT
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Gender | Female
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Dates
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Enumeration Date | 10/22/2007
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Last Update Date | 01/15/2025
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Provider Practice Location Address
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Address Line | 183 PEACE BLVD
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-9146
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Country | US
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Telephone | 269-408-1636
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Fax | 269-429-6451
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Provider Business Mailing Address
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Address Line | 183 PEACE BLVD
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-9146
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Country | US
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Telephone | 269-408-1636
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Fax | 269-429-6451
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 05009436A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501013985
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License Number State | MI
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