Provider Demographics
NPI:1396021739
Name:BURNETT, FRED ALBERT IV (ATC)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:ALBERT
Last Name:BURNETT
Suffix:IV
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 ORCHARD POND DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8308
Mailing Address - Country:US
Mailing Address - Phone:904-278-3057
Mailing Address - Fax:
Practice Address - Street 1:1 UNF DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7699
Practice Address - Country:US
Practice Address - Phone:904-620-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL27182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer