Provider Demographics
NPI:1699025262
Name:FULTZ, ELSA BENIGNO (LMP)
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:BENIGNO
Last Name:FULTZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2848
Mailing Address - Country:US
Mailing Address - Phone:206-707-1768
Mailing Address - Fax:
Practice Address - Street 1:1100 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2848
Practice Address - Country:US
Practice Address - Phone:206-707-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60303177225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist