=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043030745
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARITA RENAE BURNETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2024
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2708 E 10TH ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-364-9789
-----------------------------------------------------
Fax | 252-364-9789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2708 E 10TH ST STE 27082708
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27858-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-364-9789
-----------------------------------------------------
Fax | 252-364-9789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224P00000X
-----------------------------------------------------
Taxonomy Name | Prosthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 224P00000X
-----------------------------------------------------
Taxonomy Name | Prosthetist
-----------------------------------------------------
License Number | 335E00000X
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------