Provider Demographics
NPI:1396864666
Name:FULTZ, MARTHA (RN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5683 US HIGHWAY 129 S
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-3743
Mailing Address - Country:US
Mailing Address - Phone:386-792-6540
Mailing Address - Fax:386-638-0049
Practice Address - Street 1:5683 US HIGHWAY 129 S
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-3743
Practice Address - Country:US
Practice Address - Phone:386-792-6540
Practice Address - Fax:386-638-0049
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2802692163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health