Provider Demographics
NPI:1447750690
Name:WULTERKENS, ROBERT THOMAS
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THOMAS
Last Name:WULTERKENS
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 1:1639 EAGLES LANDING BLVD APT 34
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1586
Mailing Address - Country:US
Mailing Address - Phone:772-971-1145
Mailing Address - Fax:
Practice Address - Street 1:1699 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1963
Practice Address - Country:US
Practice Address - Phone:904-306-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist