Provider Demographics
NPI:1356796726
Name:FULTZ, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FULTZ
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 1:677 E. MAIN ST./STE A
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-3071
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:
Practice Address - Street 1:677 E. MAIN ST./STE A
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-3071
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist