Provider Demographics
NPI:1982861944
Name:FULTZ, REBECCA LU (RN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LU
Last Name:FULTZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 93RD AVE APT C
Mailing Address - Street 2:
Mailing Address - City:DRESSER
Mailing Address - State:WI
Mailing Address - Zip Code:54009-4627
Mailing Address - Country:US
Mailing Address - Phone:171-555-4204
Mailing Address - Fax:
Practice Address - Street 1:1848 93RD AVE APT C
Practice Address - Street 2:
Practice Address - City:DRESSER
Practice Address - State:WI
Practice Address - Zip Code:54009-4627
Practice Address - Country:US
Practice Address - Phone:171-555-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306538-031164W00000X
WI174688-030163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3950845470Medicaid