Provider Demographics
NPI:1235547894
Name:FULLERTON, CARLY (MSS ATC)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MSS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-3137
Mailing Address - Country:US
Mailing Address - Phone:703-407-8076
Mailing Address - Fax:
Practice Address - Street 1:201 HIGH ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23909-1800
Practice Address - Country:US
Practice Address - Phone:434-395-2965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260013402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer