Healthcare Provider Details

I. General information

NPI: 1558649400
Provider Name (Legal Business Name): CYNTHIA FULTON RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 PARK PLACE CT
ARLINGTON TX
76016-5868
US

IV. Provider business mailing address

2702 PARK PLACE CT
ARLINGTON TX
76016-5868
US

V. Phone/Fax

Practice location:
  • Phone: 817-896-9031
  • Fax: 817-801-9031
Mailing address:
  • Phone: 817-896-9031
  • Fax: 817-801-9031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT02348
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT02348
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDT02348
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: