Provider Demographics
NPI:1104645373
Name:BURT, KASONDRA JO (LPN)
Entity type:Individual
Prefix:
First Name:KASONDRA
Middle Name:JO
Last Name:BURT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WARREN RDG
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-7932
Mailing Address - Country:US
Mailing Address - Phone:601-910-5989
Mailing Address - Fax:
Practice Address - Street 1:104 WARREN RDG
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-7932
Practice Address - Country:US
Practice Address - Phone:601-910-5989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP321804164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse