Provider Demographics
NPI:1447514872
Name:FULMER, EMILY P (OTR)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:P
Last Name:FULMER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:P
Other - Last Name:DELACRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:2425 E SOUTHLAKE BLVD
Mailing Address - Street 2:# 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6674
Mailing Address - Country:US
Mailing Address - Phone:817-442-0222
Mailing Address - Fax:817-442-0223
Practice Address - Street 1:2425 E SOUTHLAKE BLVD
Practice Address - Street 2:# 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6674
Practice Address - Country:US
Practice Address - Phone:817-442-0222
Practice Address - Fax:817-442-0223
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109922174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist