Provider Demographics
NPI:1144263708
Name:FULTON, JANE LESLEY (PT)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:LESLEY
Last Name:FULTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1156
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-1156
Mailing Address - Country:US
Mailing Address - Phone:941-721-9100
Mailing Address - Fax:941-721-9119
Practice Address - Street 1:2650 BAHIA VISTA ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2635
Practice Address - Country:US
Practice Address - Phone:941-906-7766
Practice Address - Fax:941-906-7767
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2989794OtherAETNA GROUP PROV NUMBER
FL890851600Medicaid
FL6697189OtherGHI INDIV PROV NUM
FLY6163OtherBCBS INDIV PROV NUM
FL890851600Medicaid