Basic Information
| Provider Information | |||||||||
| NPI: | 1265057509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNETT | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | HANKIN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1714 CANTERBURY RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276081110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197916678 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10820 PENNY RD | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275181916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193720417 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2020 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 8942 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P19606 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P19606 | 05 | NC | MEDICAID | P19606 | 01 | NC | MEDICARE | OTHER |