Provider Demographics
NPI:1689929507
Name:FULTS, ANGELA (DO)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:FULTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1261
Mailing Address - Country:US
Mailing Address - Phone:319-741-6789
Mailing Address - Fax:
Practice Address - Street 1:105 9TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:IA
Practice Address - Zip Code:52208-2200
Practice Address - Country:US
Practice Address - Phone:319-444-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR9445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine