MEDICARE: COLLENE FULTON ELECTROLOGIST

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	174V00000X	Clinical Ethicist	COZ0501949	CO

General Provider Information

NPI Number	:	1356741052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLENE FULTON ELECTROLOGIST

Provider Business Mailing Address
First Line	:	1225 CIMARRON DR
Second Line	:	SUITE 201
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-3812
Country	:	US
Telephone Number	:	303-421-1106
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 CIMARRON DR
Second Line	:	SUITE 201
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-3812
Country	:	US
Telephone Number	:	303-421-1106
Fax Number	:

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

Provider Enumeration Date	:	08/29/2014
Last Update Date	:	08/29/2014

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