Provider Demographics
NPI:1003393505
Name:FULGENCIO, DAPHNEY
Entity type:Individual
Prefix:
First Name:DAPHNEY
Middle Name:
Last Name:FULGENCIO
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 1:197 WESTMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-3845
Mailing Address - Country:US
Mailing Address - Phone:650-822-3662
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066
Practice Address - Country:US
Practice Address - Phone:650-243-9849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW224043386OtherAETNA