Provider Demographics
NPI:1730624925
Name:FULTZ, SHELBY LOUISE
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LOUISE
Last Name:FULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4879 TARRY GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7565
Mailing Address - Country:US
Mailing Address - Phone:770-601-3262
Mailing Address - Fax:
Practice Address - Street 1:748 W VINCENT DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-6547
Practice Address - Country:US
Practice Address - Phone:706-389-2954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist