Provider Demographics
NPI:1538381439
Name:FULTZ, PAULA DAVIS (PCC-S,RD,LD)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:DAVIS
Last Name:FULTZ
Suffix:
Gender:F
Credentials:PCC-S,RD,LD
Other - Prefix:MRS
Other - First Name:PAULA
Other - Middle Name:ANN
Other - Last Name:FULTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PCC-S,RD,LD
Mailing Address - Street 1:10509 KINGS WAY
Mailing Address - Street 2:
Mailing Address - City:N. ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-1970
Mailing Address - Country:US
Mailing Address - Phone:440-582-3744
Mailing Address - Fax:
Practice Address - Street 1:303 E. BAGLEY ROAD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017
Practice Address - Country:US
Practice Address - Phone:440-260-8375
Practice Address - Fax:440-260-8390
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0003210SUPV101YM0800X
OHLD861133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered