Provider Demographics
NPI:1306575519
Name:FULFORD, MEGAN RENEE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:RENEE
Last Name:FULFORD
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 1:28526 ALESSANDRIA CIR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8273
Mailing Address - Country:US
Mailing Address - Phone:313-303-4740
Mailing Address - Fax:
Practice Address - Street 1:3735 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9302
Practice Address - Country:US
Practice Address - Phone:239-277-3977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant