Provider Demographics
NPI:1063976512
Name:BURGESS, JENNIFER (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 GRAY ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4037
Mailing Address - Country:US
Mailing Address - Phone:727-432-0735
Mailing Address - Fax:
Practice Address - Street 1:4054 SAWYER RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1272
Practice Address - Country:US
Practice Address - Phone:941-552-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily