Basic Information
| Provider Information | |||||||||
| NPI: | 1255808754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURBANK | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 531 ROSELANE ST NW STE 710 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300606975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783313297 | ||||||||
| FaxNumber: | 6785817187 | ||||||||
| Practice Location | |||||||||
| Address1: | 6002 PROFESSIONAL PKWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301345627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787159690 | ||||||||
| FaxNumber: | 6785817140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN217757 | GA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | RN217757 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1255808754 | 01 | GA | NPI NUMBER | OTHER |