Provider Demographics
NPI:1942818851
Name:BURKETT, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:BURKETT
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 1:1 JOYFUL BROOKE LN
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-6316
Mailing Address - Country:US
Mailing Address - Phone:618-565-1077
Mailing Address - Fax:
Practice Address - Street 1:2 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-3333
Practice Address - Country:US
Practice Address - Phone:618-684-3156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019591208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation