Provider Demographics
NPI:1174733315
Name:FULFER, MELISSA ANN (LMP)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:FULFER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:958 W CASINO RD APT 2
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-8165
Mailing Address - Country:US
Mailing Address - Phone:425-322-5476
Mailing Address - Fax:
Practice Address - Street 1:12704 MUKILTEO SPEEDWAY STE C
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5720
Practice Address - Country:US
Practice Address - Phone:425-290-1919
Practice Address - Fax:425-353-9690
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist