Provider Demographics
NPI:1104542372
Name:BURKE, DESIREE LAUREL LAUREL ANNE (NP)
Entity type:Individual
Prefix:
First Name:DESIREE LAUREL
Middle Name:LAUREL ANNE
Last Name:BURKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 PAULSEN RD
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-8416
Mailing Address - Country:US
Mailing Address - Phone:815-440-9733
Mailing Address - Fax:
Practice Address - Street 1:100 E LEFEVRE RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1279
Practice Address - Country:US
Practice Address - Phone:815-625-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL209.026257363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program