Healthcare Provider Details

I. General information

NPI: 1457076002
Provider Name (Legal Business Name): MAISIE FULTON OTD/R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

664 12TH ST W STE C
DICKINSON ND
58601-3511
US

IV. Provider business mailing address

870 PHEASANT RUN AVE
DICKINSON ND
58601-6536
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-3899
  • Fax: 701-483-3889
Mailing address:
  • Phone: 701-483-3899
  • Fax: 701-483-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: