MEDICARE: ANGELA FULTZ M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	4297	OK

General Provider Information

NPI Number	:	1073665402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA FULTZ M.A.

Provider Business Mailing Address
First Line	:	5700 N PORTLAND AVE STE 310
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-1648
Country	:	US
Telephone Number	:	405-602-2984
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 N PORTLAND AVE STE 310
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-1648
Country	:	US
Telephone Number	:	405-602-2984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	03/28/2016

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