MEDICARE: STEPHANIE THERESA BURNETT NP-C

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	RN167982	GA

General Provider Information

NPI Number	:	1477135200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE THERESA BURNETT NP-C

Provider Business Mailing Address
First Line	:	PO BOX 925
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30903-0925
Country	:	US
Telephone Number	:	706-724-8611
Fax Number	:	706-724-6202

Provider Business Practice Location Address
First Line	:	2460 WASHINGTON RD
Second Line	:
City	:	THOMSON
State	:	GA
Zip	:	30824-6600
Country	:	US
Telephone Number	:	706-595-1411
Fax Number	:

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

Provider Enumeration Date	:	04/21/2021
Last Update Date	:	03/10/2022

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