Provider Demographics
NPI:1285758490
Name:FULLERTON, PAMELA MARIE (MED)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:MARIE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 N 6TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-2411
Mailing Address - Country:US
Mailing Address - Phone:610-965-3633
Mailing Address - Fax:
Practice Address - Street 1:23 N 6TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049-2411
Practice Address - Country:US
Practice Address - Phone:610-965-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional