Basic Information
| Provider Information | |||||||||
| NPI: | 1003146614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULGENCIO | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | JOSEPHINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5275 MARKET ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921142212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192637090 | ||||||||
| FaxNumber: | 6192637343 | ||||||||
| Practice Location | |||||||||
| Address1: | 5275 MARKET ST | ||||||||
| Address2: | SUITE G | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921142212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192637090 | ||||||||
| FaxNumber: | 6192637343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2010 | ||||||||
| LastUpdateDate: | 05/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.