Provider Demographics
NPI:1891208021
Name:BURRIS, RENEE HELENE (LPN)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:HELENE
Last Name:BURRIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 TERWILLIGER ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-1769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 TERWILLIGER ROAD EXT
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538-1769
Practice Address - Country:US
Practice Address - Phone:845-505-4320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323142164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse