Provider Demographics
NPI:1285785428
Name:BURGOS, LAILATULLAH (APRN, NP-C)
Entity type:Individual
Prefix:MS
First Name:LAILATULLAH
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 S PALMETTO AVE APT 100
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-6161
Mailing Address - Country:US
Mailing Address - Phone:407-592-0742
Mailing Address - Fax:
Practice Address - Street 1:37840 MEDICAL ARTS CT
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33541-4325
Practice Address - Country:US
Practice Address - Phone:352-518-2000
Practice Address - Fax:352-567-0218
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9232091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307127800Medicaid
FL017846500Medicaid