Healthcare Provider Details

I. General information

NPI: 1356728398
Provider Name (Legal Business Name): PAMMIE FULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17515 ROCKAWAY BLVD
JAMAICA NY
11434-5503
US

IV. Provider business mailing address

17515 ROCKAWAY BLVD
JAMAICA NY
11434-5503
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-2300
  • Fax: 718-632-1568
Mailing address:
  • Phone: 718-632-3275
  • Fax: 718-632-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number40503
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: