Provider Demographics
NPI:1124633029
Name:BURRUS, KANEISHA
Entity type:Individual
Prefix:
First Name:KANEISHA
Middle Name:
Last Name:BURRUS
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 1:10853 MISTFLOWER WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-3563
Mailing Address - Country:US
Mailing Address - Phone:317-406-1299
Mailing Address - Fax:
Practice Address - Street 1:10853 MISTFLOWER WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-3563
Practice Address - Country:US
Practice Address - Phone:317-406-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200148913747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty