Provider Demographics
NPI:1063077790
Name:BURNETT, NIKEYA SEREEN
Entity type:Individual
Prefix:
First Name:NIKEYA
Middle Name:SEREEN
Last Name:BURNETT
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 1:12 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1717
Mailing Address - Country:US
Mailing Address - Phone:631-889-3394
Mailing Address - Fax:
Practice Address - Street 1:12 PERRY ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1717
Practice Address - Country:US
Practice Address - Phone:631-889-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAEC-19-01291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty