Provider Demographics
NPI:1982385779
Name:FULLERTON, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:FULLERTON
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 1:1928 SAGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7330
Mailing Address - Country:US
Mailing Address - Phone:850-508-3646
Mailing Address - Fax:
Practice Address - Street 1:1928 SAGEWAY DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-7330
Practice Address - Country:US
Practice Address - Phone:850-508-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008000225X00000X
FLOT19086225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist