Provider Demographics
NPI:1124836721
Name:FULTON, WILLIMAE
Entity type:Individual
Prefix:MS
First Name:WILLIMAE
Middle Name:
Last Name:FULTON
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 1:255 NEWCO RD
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-8938
Mailing Address - Country:US
Mailing Address - Phone:512-665-2382
Mailing Address - Fax:
Practice Address - Street 1:255 NEWCO RD
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-8938
Practice Address - Country:US
Practice Address - Phone:512-665-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM10605104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker