Provider Demographics
NPI:1194580688
Name:FULTON, REYNALDO C
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:C
Last Name:FULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 ATHENS DR SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3445
Mailing Address - Country:US
Mailing Address - Phone:234-600-3495
Mailing Address - Fax:
Practice Address - Street 1:2731 ATHENS DR SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3445
Practice Address - Country:US
Practice Address - Phone:234-600-3495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker