Basic Information
| Provider Information | |||||||||
| NPI: | 1154506772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULATEK | ||||||||
| FirstName: | CLARISSA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANTON | ||||||||
| OtherFirstName: | CLARISSA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | D.P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | 9193131276 | ||||||||
| Practice Location | |||||||||
| Address1: | 11550 COMMON OAKS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276147298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194535740 | ||||||||
| FaxNumber: | 9194535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12562 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.