Provider Demographics
NPI:1174088058
Name:BURDETTE, BOBBIE JO
Entity type:Individual
Prefix:
First Name:BOBBIE
Middle Name:JO
Last Name:BURDETTE
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 1:202 CORBIN HEIGHTS CIR
Mailing Address - Street 2:
Mailing Address - City:GIVEN
Mailing Address - State:WV
Mailing Address - Zip Code:25245-8072
Mailing Address - Country:US
Mailing Address - Phone:304-532-4463
Mailing Address - Fax:
Practice Address - Street 1:202 CORBIN HEIGHTS CIR
Practice Address - Street 2:
Practice Address - City:GIVEN
Practice Address - State:WV
Practice Address - Zip Code:25245-8072
Practice Address - Country:US
Practice Address - Phone:304-532-4463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN44075NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily