Basic Information
| Provider Information | |||||||||
| NPI: | 1356484133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULMER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | GLOGER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 ASHLYN DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329041940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214032204 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2082 SARNO RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212552818 | ||||||||
| FaxNumber: | 3212554901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | PT 20631 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.