Basic Information
| Provider Information | |||||||||
| NPI: | 1225779036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNETTE | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | ALTISON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1404 RACE ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452027366 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 178 PRIVATE ROAD 19423 | ||||||||
| Address2: | |||||||||
| City: | SOUTH POINT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456808831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405341386 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN.181539.MEDS-IV | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.