Provider Demographics
NPI:1063621498
Name:FULK, MICHELLE LEA
Entity type:Individual
Prefix:MR
First Name:MICHELLE
Middle Name:LEA
Last Name:FULK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-7029
Mailing Address - Country:US
Mailing Address - Phone:608-361-9881
Mailing Address - Fax:
Practice Address - Street 1:2530 SHADY LN
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-7029
Practice Address - Country:US
Practice Address - Phone:608-361-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist