Provider Demographics
NPI:1427574904
Name:FULTYN, CHRISTINE (PSYD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:FULTYN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-2240
Mailing Address - Country:US
Mailing Address - Phone:417-862-7041
Mailing Address - Fax:
Practice Address - Street 1:1900 W SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-2240
Practice Address - Country:US
Practice Address - Phone:417-862-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical