1699053124 NPI number — MRS. DEVON NICOLE FULTS M.A., LPC

Table of content: MRS. DEVON NICOLE FULTS M.A., LPC (NPI 1699053124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699053124 NPI number — MRS. DEVON NICOLE FULTS M.A., LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULTS
Provider First Name:
DEVON
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRAKES
Provider Other First Name:
DEVON
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699053124
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7980 ANCHOR DRIVE
Provider Second Line Business Mailing Address:
BUILDING 500
Provider Business Mailing Address City Name:
PORT ARTHUR
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77642-8285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-727-6400
Provider Business Mailing Address Fax Number:
409-727-6403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7980 ANCHOR DRIVE
Provider Second Line Business Practice Location Address:
BUILDING 500
Provider Business Practice Location Address City Name:
PORT ARTHUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77642-8285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-727-6400
Provider Business Practice Location Address Fax Number:
409-727-6403
Provider Enumeration Date:
08/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  65305 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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