1215223011 NPI number — CAITLIN A BURLESON NP-C

Table of content: CAITLIN A BURLESON NP-C (NPI 1215223011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215223011 NPI number — CAITLIN A BURLESON NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURLESON
Provider First Name:
CAITLIN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
CAITLIN
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215223011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PLANTATION ST
Provider Second Line Business Mailing Address:
WOT 12TH FL
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-368-5532
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 SUMMER ST
Provider Second Line Business Practice Location Address:
SUITE 320
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-368-3140
Provider Business Practice Location Address Fax Number:
508-368-3196
Provider Enumeration Date:
06/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN2268039 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 064334-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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