Healthcare Provider Details

I. General information

NPI: 1922449313
Provider Name (Legal Business Name): CARLY DION FULTZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARLY DION PANTON

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4307 1ST AVE NE
BRADENTON FL
34208-5431
US

IV. Provider business mailing address

4307 1ST AVE NE
BRADENTON FL
34208-5431
US

V. Phone/Fax

Practice location:
  • Phone: 941-961-0645
  • Fax:
Mailing address:
  • Phone: 941-961-0645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA23455
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: