Provider Demographics
NPI:1306055900
Name:BURGESS, PHYLLIS VERONICA (APN MSN)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:VERONICA
Last Name:BURGESS
Suffix:
Gender:F
Credentials:APN MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9700 S CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1717
Mailing Address - Country:US
Mailing Address - Phone:773-233-2509
Mailing Address - Fax:
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-864-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001005364SN0000X
IL209001006363LN0000X
IL041162850163W00000X
IL041-162850163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care