Provider Demographics
NPI:1154148161
Name:FULTCHER, KIMBERLY MONICE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MONICE
Last Name:FULTCHER
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 1:2151 POCK LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-7763
Mailing Address - Country:US
Mailing Address - Phone:209-361-4455
Mailing Address - Fax:
Practice Address - Street 1:2151 POCK LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-7763
Practice Address - Country:US
Practice Address - Phone:209-361-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician