Healthcare Provider Details

I. General information

NPI: 1437036720
Provider Name (Legal Business Name): CYNTHIA EILEEN FULTS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 W HIGHWAY 92 STE 4
WILLIAMSBURG KY
40769-1936
US

IV. Provider business mailing address

640 W HIGHWAY 92 STE 4
WILLIAMSBURG KY
40769-1936
US

V. Phone/Fax

Practice location:
  • Phone: 606-539-7257
  • Fax: 606-539-7256
Mailing address:
  • Phone: 606-539-7257
  • Fax: 606-539-7256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number00854
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: