Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 6540 | TN |
NPI | 1073178141 |
---|---|
Provider Name | Kelly Fulgham |
First Address | Collierville, TN 38017-9710 |
Second Address | Memphis, TN 38120-4367 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2019 |
Last Update Date | 04/05/2019 |