Provider Demographics
NPI:1700525698
Name:FULCHER, STACY DAWN (PTA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:DAWN
Last Name:FULCHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 GRAND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROLESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27571-9527
Mailing Address - Country:US
Mailing Address - Phone:757-349-4728
Mailing Address - Fax:
Practice Address - Street 1:262 TOLLGATE RD
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1377
Practice Address - Country:US
Practice Address - Phone:215-968-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE012764225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant