Provider Demographics
NPI:1558669762
Name:FULTON, ABIGAIL JORDAN
Entity Type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:JORDAN
Last Name:FULTON
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 1:6530 MAYWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-1246
Mailing Address - Country:US
Mailing Address - Phone:740-251-8721
Mailing Address - Fax:
Practice Address - Street 1:6530 MAYWOOD CIR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46819-1246
Practice Address - Country:US
Practice Address - Phone:740-251-8721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003847A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant