Provider Demographics
NPI:1447600937
Name:FULGHUM, BONNIE A (LMBT)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:A
Last Name:FULGHUM
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 FULGHUM RD
Mailing Address - Street 2:
Mailing Address - City:KENLY
Mailing Address - State:NC
Mailing Address - Zip Code:27542-8202
Mailing Address - Country:US
Mailing Address - Phone:252-289-3786
Mailing Address - Fax:
Practice Address - Street 1:7617 FULGHUM RD
Practice Address - Street 2:
Practice Address - City:KENLY
Practice Address - State:NC
Practice Address - Zip Code:27542-8202
Practice Address - Country:US
Practice Address - Phone:252-289-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14869225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist