Provider Demographics
NPI:1154506772
Name:BULATEK, CLARISSA NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:NICOLE
Last Name:BULATEK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:NICOLE
Other - Last Name:STANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:120 WILLIAM PENN PLZ
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2150
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-313-1276
Practice Address - Street 1:11550 COMMON OAKS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7298
Practice Address - Country:US
Practice Address - Phone:919-453-5740
Practice Address - Fax:919-453-5741
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2506119Medicare PIN