Provider Demographics
NPI:1407649353
Name:FULTON, TAMIKA RAYNELLE
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:RAYNELLE
Last Name:FULTON
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 1:1950 N WALNUT RD APT 114
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-6422
Mailing Address - Country:US
Mailing Address - Phone:702-884-4678
Mailing Address - Fax:
Practice Address - Street 1:3275 S JONES BLVD STE 106
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6768
Practice Address - Country:US
Practice Address - Phone:725-237-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7634002246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist