Provider Demographics
NPI:1124256201
Name:FULTS, PATRICIA A (MDH)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:FULTS
Suffix:
Gender:F
Credentials:MDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-5265
Mailing Address - Country:US
Mailing Address - Phone:850-227-1276
Mailing Address - Fax:850-227-9101
Practice Address - Street 1:2475 GARRISON AVE
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5265
Practice Address - Country:US
Practice Address - Phone:850-227-1276
Practice Address - Fax:850-227-9101
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH5687124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist