Provider Demographics
NPI:1922191592
Name:FULMER, DIANA M
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:FULMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:M
Other - Last Name:CORZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSY D
Mailing Address - Street 1:5790 MAGNOLIA AVE #202
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1874
Mailing Address - Country:US
Mailing Address - Phone:909-625-7730
Mailing Address - Fax:909-625-3352
Practice Address - Street 1:5790 MAGNOLIA AVE #202
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1874
Practice Address - Country:US
Practice Address - Phone:909-625-7730
Practice Address - Fax:909-625-3352
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPL 8178103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL81781Medicare ID - Type Unspecified