Provider Demographics
NPI:1194914648
Name:BURGESS, NICOLE LYNN (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 PEACE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9146
Mailing Address - Country:US
Mailing Address - Phone:269-408-1636
Mailing Address - Fax:269-429-6451
Practice Address - Street 1:183 PEACE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9146
Practice Address - Country:US
Practice Address - Phone:269-408-1636
Practice Address - Fax:269-429-6451
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009436A225100000X
MI5501013985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200876240Medicaid