Provider Demographics
NPI:1558168930
Name:FULTZ, KELLY (RN, BSN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FULTZ
Suffix:
Gender:
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 BONITA DR.
Mailing Address - Street 2:APT 9
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042
Mailing Address - Country:US
Mailing Address - Phone:513-465-4242
Mailing Address - Fax:
Practice Address - Street 1:4175 BONITA DR.
Practice Address - Street 2:APT 9
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042
Practice Address - Country:US
Practice Address - Phone:513-465-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH524967163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse