Provider Demographics
NPI:1063729754
Name:BURNHAM, AMY LYNN (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:BURNHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:KEEGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7668
Mailing Address - Country:US
Mailing Address - Phone:770-781-8004
Mailing Address - Fax:678-679-4054
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7668
Practice Address - Country:US
Practice Address - Phone:770-781-8004
Practice Address - Fax:678-679-4054
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant