Provider Demographics
NPI:1417337981
Name:FULTS, MALLORIE
Entity Type:Individual
Prefix:MS
First Name:MALLORIE
Middle Name:
Last Name:FULTS
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 1:805 SE 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-2916
Mailing Address - Country:US
Mailing Address - Phone:971-271-7270
Mailing Address - Fax:971-302-6046
Practice Address - Street 1:805 SE 151ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2916
Practice Address - Country:US
Practice Address - Phone:971-271-7270
Practice Address - Fax:971-302-6046
Is Sole Proprietor?:No
Enumeration Date:2015-05-31
Last Update Date:2015-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist