Provider Demographics
NPI:1164057782
Name:FULCHER, SHAUNTE
Entity Type:Individual
Prefix:
First Name:SHAUNTE
Middle Name:
Last Name:FULCHER
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 1:1512 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2150
Mailing Address - Country:US
Mailing Address - Phone:404-844-1123
Mailing Address - Fax:
Practice Address - Street 1:2804 PRICE AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4214
Practice Address - Country:US
Practice Address - Phone:404-844-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF426794809080172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000000000OtherN/A