Provider Demographics
NPI:1508120700
Name:FULLERTON, MISTY MARIE (DC)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MARIE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-6646
Mailing Address - Country:US
Mailing Address - Phone:602-242-7537
Mailing Address - Fax:602-242-4169
Practice Address - Street 1:2801 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-6646
Practice Address - Country:US
Practice Address - Phone:602-242-7537
Practice Address - Fax:602-242-4169
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8252111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor