Provider Demographics
NPI:1871837815
Name:FULKER, ALISHA M (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:M
Last Name:FULKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 MESQUITE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5777
Mailing Address - Country:US
Mailing Address - Phone:928-854-4776
Mailing Address - Fax:928-854-4857
Practice Address - Street 1:1948 MESQUITE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5777
Practice Address - Country:US
Practice Address - Phone:928-854-4776
Practice Address - Fax:928-854-4857
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist