Provider Demographics
NPI:1922449313
Name:FULTZ, CARLY DION (PTA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:DION
Last Name:FULTZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:DION
Other - Last Name:PANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4307 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5431
Mailing Address - Country:US
Mailing Address - Phone:941-961-0645
Mailing Address - Fax:
Practice Address - Street 1:4307 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5431
Practice Address - Country:US
Practice Address - Phone:941-961-0645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23455225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant