Provider Demographics
NPI:1245308717
Name:HULSE, LETICIA ANN GOODPASTURE
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:ANN GOODPASTURE
Last Name:HULSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LETICIA
Other - Middle Name:ANN
Other - Last Name:GOODPASTURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10407 ELM RD
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-7347
Mailing Address - Country:US
Mailing Address - Phone:573-406-8694
Mailing Address - Fax:
Practice Address - Street 1:10407 ELM RD
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-7347
Practice Address - Country:US
Practice Address - Phone:573-406-8694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist