MEDICARE: MRS. GRACE ELIZABETH BURNHAM LMT

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	174400000X	Specialist	MA43029	FL

General Provider Information

NPI Number	:	1477731123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE ELIZABETH BURNHAM LMT

Provider Business Mailing Address
First Line	:	1637 RACE TRACK RD
Second Line	:	SUITE 237
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-3239
Country	:	US
Telephone Number	:	904-287-8306
Fax Number	:	904-287-3413

Provider Business Practice Location Address
First Line	:	1637 RACE TRACK RD
Second Line	:	SUITE 237
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-3239
Country	:	US
Telephone Number	:	904-287-8306
Fax Number	:	904-287-3413

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

Provider Enumeration Date	:	02/05/2008
Last Update Date	:	02/05/2008

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