Provider Demographics
NPI:1902247778
Name:BURKE, PRENTISS
Entity Type:Individual
Prefix:
First Name:PRENTISS
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 27TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:ALASKA
Practice Address - Zip Code:99701
Practice Address - Country:UM
Practice Address - Phone:404-259-7674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA081170164W00000X
TN77580376K00000X
TN61932164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide