Provider Demographics
NPI:1255645784
Name:BURNETT, BETTY JEAN (LMT)
Entity type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:JEAN
Last Name:BURNETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 NE COUNTY ROAD 219A
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666-6006
Mailing Address - Country:US
Mailing Address - Phone:904-263-8008
Mailing Address - Fax:352-475-1013
Practice Address - Street 1:5998 CENTRE ST
Practice Address - Street 2:STE F
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-6208
Practice Address - Country:US
Practice Address - Phone:904-263-8008
Practice Address - Fax:352-475-1013
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA33800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1845OtherBLUE CROSS BLUE SHIELD OF FLORIDA