Basic Information
| Provider Information | |||||||||
| NPI: | 1710138557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURLESON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2880 TRICOM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437975050 | ||||||||
| FaxNumber: | 8437973633 | ||||||||
| Practice Location | |||||||||
| Address1: | 2880 TRICOM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437975050 | ||||||||
| FaxNumber: | 8437973633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2008 | ||||||||
| LastUpdateDate: | 08/31/2009 | ||||||||
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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 | 363LA2200X | 3593 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 20076508 | 01 | SC | SELECT HEALTH DME | OTHER | 1326287434 | 01 | SC | MEDICAID DME NPI | OTHER | 1701 | 01 | SC | GROUP MEDICARE | OTHER | 57-0634057 | 01 | SC | GROUP TAX ID # | OTHER | NP1368 | 05 | SC | MEDICAID | 1225006760 | 01 | SC | GROUP NPI NO. | OTHER | 20083697 | 01 | SC | SELECT HEALTH FIRST CHOICE | OTHER | 56162 | 01 | SC | MEDCOST | OTHER |