=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700546223
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSANDRA ANN BURKS PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2021
-----------------------------------------------------
Last Update Date | 10/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 PAPAGO CT
-----------------------------------------------------
City | RANDALLSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21133-1746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-983-3211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 PAPAGO CT
-----------------------------------------------------
City | RANDALLSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21133-1746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-983-3211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R207717
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------