=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982945069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORLISTA ANNE BURGESS CNM, PHMNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2013
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 E PEMBROKE AVE
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23664-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-810-2663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2604 E PEMBROKE AVE
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23664-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-810-2663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 176B00000X
-----------------------------------------------------
Taxonomy Name | Midwife
-----------------------------------------------------
License Number | 0024170057
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 0024170057
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------