MEDICARE: STACI D BURRELL FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1143	SC
2	363LF0000X	Family Nurse Practitioner	201126	NC

General Provider Information

NPI Number	:	1114953106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI D BURRELL FNP

Provider Business Mailing Address
First Line	:	3125 SPRINGBANK LN STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-3379
Country	:	US
Telephone Number	:	803-517-8478
Fax Number	:	704-235-1666

Provider Business Practice Location Address
First Line	:	3125 SPRINGBANK LN STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-3379
Country	:	US
Telephone Number	:	704-752-9346
Fax Number	:	704-235-1666

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/30/2024

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