Provider Demographics
NPI:1093298804
Name:CRUNKLETON, WANDA LISA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:LISA
Last Name:CRUNKLETON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 WATERY BRANCH CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:STANTONSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27883-9179
Mailing Address - Country:US
Mailing Address - Phone:919-920-3850
Mailing Address - Fax:
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC604225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant