Provider Demographics
NPI:1356186159
Name:BURDICK, AGATHA CHULU
Entity type:Individual
Prefix:
First Name:AGATHA
Middle Name:CHULU
Last Name:BURDICK
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 1:10655 PEARL BERRY LOOP
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-6938
Mailing Address - Country:US
Mailing Address - Phone:720-254-0058
Mailing Address - Fax:
Practice Address - Street 1:7300 GROVE RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6012
Practice Address - Country:US
Practice Address - Phone:352-549-9759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033654363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health