Provider Demographics
NPI:1245304708
Name:FULFER, NANCY D (PT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:D
Last Name:FULFER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:DEPT 441 THE PAIN CLINIC PHYSICAL THERAPY
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0441
Mailing Address - Country:US
Mailing Address - Phone:901-747-0040
Mailing Address - Fax:901-747-4340
Practice Address - Street 1:55 HUMPHREYS CENTER DR
Practice Address - Street 2:SUITE 200 THE PAIN CLINIC PHYSICAL THERAPY
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2366
Practice Address - Country:US
Practice Address - Phone:901-747-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000000446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4061923OtherBLUE CROSS TN
TN3658435Medicaid
TN4061923OtherBLUE CROSS TN