Provider Demographics
NPI:1053184465
Name:FULFORD, PATRICIA RENEE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:RENEE
Last Name:FULFORD
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:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-0678
Mailing Address - Country:US
Mailing Address - Phone:631-902-9272
Mailing Address - Fax:
Practice Address - Street 1:1750 W MAIN ST APT C6
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3130
Practice Address - Country:US
Practice Address - Phone:631-902-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker