Provider Demographics
NPI:1194221044
Name:FULFORD, KAITLYN BURRICHTER
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:BURRICHTER
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 1:1507 LINDEN AVE APT 19
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-7379
Mailing Address - Country:US
Mailing Address - Phone:615-598-4768
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS WAY # 512-19A
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-31
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program