Provider Demographics
NPI:1942405030
Name:FULLERTON, JOSEFINA DUMAGAT
Entity Type:Individual
Prefix:
First Name:JOSEFINA
Middle Name:DUMAGAT
Last Name:FULLERTON
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 1:1406 AMBASSADOR DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-2522
Mailing Address - Country:US
Mailing Address - Phone:727-524-6955
Mailing Address - Fax:
Practice Address - Street 1:2770 REGENCY OAKS BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1509
Practice Address - Country:US
Practice Address - Phone:727-791-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist