Provider Demographics
NPI:1871940346
Name:BURGESS, BETTY (LVN)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:CAROL
Other - Last Name:GANDEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:107 MIMOSA ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5645
Mailing Address - Country:US
Mailing Address - Phone:979-665-2792
Mailing Address - Fax:
Practice Address - Street 1:107 MIMOSA ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5645
Practice Address - Country:US
Practice Address - Phone:979-665-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-15
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX180236164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse