MEDICARE: MRS. DELORES MAE BURGESS NURSE PRACTITIONER

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	641179	TX

General Provider Information

NPI Number	:	1417144833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DELORES MAE BURGESS NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	2815 S HAMPTON RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-2329
Country	:	US
Telephone Number	:	214-333-7333
Fax Number	:	214-333-7342

Provider Business Practice Location Address
First Line	:	2815 S HAMPTON RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75224-2329
Country	:	US
Telephone Number	:	214-333-7333
Fax Number	:	214-333-7342

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

Provider Enumeration Date	:	09/30/2007
Last Update Date	:	03/05/2008

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