Provider Demographics
NPI:1104412717
Name:BURGETT, JONNIE MIRANDA BLAIR
Entity type:Individual
Prefix:MS
First Name:JONNIE
Middle Name:MIRANDA BLAIR
Last Name:BURGETT
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 1:6276 KEYSTONE RD
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:OH
Mailing Address - Zip Code:45686-8957
Mailing Address - Country:US
Mailing Address - Phone:740-978-6156
Mailing Address - Fax:
Practice Address - Street 1:6276 KEYSTONE RD
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:OH
Practice Address - Zip Code:45686-8957
Practice Address - Country:US
Practice Address - Phone:740-978-6156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide