=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902557515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE RENEE BURKARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2022
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 MAGNOLIA TREE RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29073-6724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-394-2495
-----------------------------------------------------
Fax | 678-937-8242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1391 NW 136TH AVE
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33323-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-218-4297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0400X
-----------------------------------------------------
Taxonomy Name | Case Management Registered Nurse
-----------------------------------------------------
License Number | 218501
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------