Provider Demographics
NPI:1366054181
Name:BURCHAK, KELLEY (FNP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BURCHAK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 DEL NORTE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-4602
Mailing Address - Country:US
Mailing Address - Phone:682-213-1381
Mailing Address - Fax:
Practice Address - Street 1:5702 LAVON DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-3126
Practice Address - Country:US
Practice Address - Phone:972-495-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily