Provider Demographics
NPI:1407510134
Name:FULWILER, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:FULWILER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 W OJAI AVE # 101-534
Mailing Address - Street 2:
Mailing Address - City:OJAI
Mailing Address - State:CA
Mailing Address - Zip Code:93023-3277
Mailing Address - Country:US
Mailing Address - Phone:206-313-1772
Mailing Address - Fax:
Practice Address - Street 1:1117 N SIGNAL ST
Practice Address - Street 2:
Practice Address - City:OJAI
Practice Address - State:CA
Practice Address - Zip Code:93023-1829
Practice Address - Country:US
Practice Address - Phone:206-313-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47026225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist