Provider Demographics
NPI:1689375214
Name:FULTON, TRACIE P (CPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:P
Last Name:FULTON
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:P
Other - Last Name:THORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPT
Mailing Address - Street 1:2823 E BIRCHDALE DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-6057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15500 VOSS RD # 1114
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77498-4601
Practice Address - Country:US
Practice Address - Phone:346-432-7892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4Y6J7Y6246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy