Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 40QA00891900 | NJ |
NPI | 1003904103 |
---|---|
Provider Name | Gwen Melisa Fulo |
First Address | Basking Ridge, NJ 07920-2718 |
Second Address | Union, NJ 07083-6013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2006 |
Last Update Date | 08/07/2007 |