Basic Information
| Provider Information | |||||||||
| NPI: | 1528067568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKETT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1360 N SAINT HELEN RD | ||||||||
| Address2: | P O BOX 39 | ||||||||
| City: | SAINT HELEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486569521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893894944 | ||||||||
| FaxNumber: | 9893891401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 N SAINT HELEN RD | ||||||||
| Address2: | |||||||||
| City: | SAINT HELEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486569521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893894944 | ||||||||
| FaxNumber: | 9893891401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704110149 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4836749 | 05 | MI | MEDICAID | 4836730 | 05 | MI | MEDICAID | 5008773520 | 01 | MI | BCBS PIN | OTHER | 700G210140 | 01 | MI | BCBS GROUP | OTHER |