Basic Information
| Provider Information | |||||||||
| NPI: | 1306076922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ALLYSON | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 684 STATE ROUTE 22B | ||||||||
| Address2: | |||||||||
| City: | PERU | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129725416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185937327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 427 MARGARET ST | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129011707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185613803 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2009 | ||||||||
| LastUpdateDate: | 07/16/2009 | ||||||||
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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 | 224Z00000X | 006469-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.