Provider Demographics
NPI:1265056691
Name:FULTON, GARY L (RN)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:FULTON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22670 E DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9090
Mailing Address - Country:US
Mailing Address - Phone:602-570-4334
Mailing Address - Fax:
Practice Address - Street 1:21258 E RITTENHOUSE RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-7579
Practice Address - Country:US
Practice Address - Phone:602-570-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN161227163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse