Basic Information
| Provider Information | |||||||||
| NPI: | 1891261863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | MEAGAN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WINCHELL | ||||||||
| OtherFirstName: | MEAGAN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 151 ANCONA AVE | ||||||||
| Address2: | |||||||||
| City: | DEBARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327135403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073615785 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1630 MASON AVE STE C | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321174503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862389064 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2018 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9366520 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.