Healthcare Provider Details

I. General information

NPI: 1033152566
Provider Name (Legal Business Name): LISA L FULTON PT,PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 CERULEAN AVE
GARDEN GROVE CA
92845-2756
US

IV. Provider business mailing address

6202 CERULEAN AVE
GARDEN GROVE CA
92845-2756
US

V. Phone/Fax

Practice location:
  • Phone: 714-347-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT15269
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT15269
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: