Provider Demographics
NPI:1144401456
Name:FULTZ, KIM F (LPTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:F
Last Name:FULTZ
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 GREEN VALLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7013
Mailing Address - Country:US
Mailing Address - Phone:336-574-3434
Mailing Address - Fax:336-574-3836
Practice Address - Street 1:804 GREEN VALLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7013
Practice Address - Country:US
Practice Address - Phone:336-574-3434
Practice Address - Fax:336-574-3836
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant