Provider Demographics
NPI:1871208173
Name:BURKE, TAYTEM ELIZABETH
Entity type:Individual
Prefix:
First Name:TAYTEM
Middle Name:ELIZABETH
Last Name:BURKE
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:PO BOX 844
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0305
Mailing Address - Country:US
Mailing Address - Phone:541-967-6580
Mailing Address - Fax:541-919-0033
Practice Address - Street 1:1305 HILL ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6711
Practice Address - Country:US
Practice Address - Phone:541-967-6580
Practice Address - Fax:541-919-0033
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR14-1872327Medicaid