=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689802639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA FAY LACELLE BURNS RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 06/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8000 W CUSTER AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53218-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-535-8980
-----------------------------------------------------
Fax | 424-535-8909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8000 W CUSTER AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53218-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-535-8980
-----------------------------------------------------
Fax | 424-535-8909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 138651-030
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------