Provider Demographics
NPI:1821646126
Name:FULK, NICOLA
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:FULK
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 1:15224 W FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4126
Mailing Address - Country:US
Mailing Address - Phone:520-256-7711
Mailing Address - Fax:
Practice Address - Street 1:2060 W WHISPERING WIND DR STE 270
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-2869
Practice Address - Country:US
Practice Address - Phone:480-653-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-16310104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker