Provider Demographics
NPI:1487057998
Name:BURTH-HUTCHINSON, KEZZY
Entity type:Individual
Prefix:
First Name:KEZZY
Middle Name:
Last Name:BURTH-HUTCHINSON
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 1:1515 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4108
Practice Address - Country:US
Practice Address - Phone:701-572-6766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1095225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant