Basic Information
| Provider Information | |||||||||
| NPI: | 1861685570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKS | ||||||||
| FirstName: | ROSLYN | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURKS | ||||||||
| OtherFirstName: | ROSLYN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1302 W 25TH AVE | ||||||||
| Address2: | |||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716035244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704139393 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4747 DUSTY LAKE DR | ||||||||
| Address2: | SUITE G-1 | ||||||||
| City: | PINE BLUFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716038742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705366600 | ||||||||
| FaxNumber: | 8705418623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2007 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A03032ANP | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A03032 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.