Basic Information
| Provider Information | |||||||||
| NPI: | 1578625331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P. A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 APPLEWOOD DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705003 | ||||||||
| FaxNumber: | 7062705111 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 SHUGART RD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705100 | ||||||||
| FaxNumber: | 7062705066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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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 | 363A00000X | 000988 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 163WP0807X | RN026508 | GA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 000988 | 01 | GA | LICENSE | OTHER |