Provider Demographics
NPI:1912521352
Name:BURSON, NIKISHIA
Entity type:Individual
Prefix:
First Name:NIKISHIA
Middle Name:
Last Name:BURSON
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 1:2507 DODSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-2445
Mailing Address - Country:US
Mailing Address - Phone:423-508-7386
Mailing Address - Fax:
Practice Address - Street 1:2507 DODSON AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-2445
Practice Address - Country:US
Practice Address - Phone:423-508-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOG6-1R7172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver