1770515728 NPI number — MRS. KIMOTHY ANN FULK APN NP C

Table of content: MRS. KIMOTHY ANN FULK APN NP C (NPI 1770515728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770515728 NPI number — MRS. KIMOTHY ANN FULK APN NP C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULK
Provider First Name:
KIMOTHY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN NP C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770515728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62439-0516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-943-2609
Provider Business Mailing Address Fax Number:
618-943-6409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11020 STATE ROUTE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62439-3379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-943-2609
Provider Business Practice Location Address Fax Number:
618-943-6409
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  209005713 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 376006178007 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 731354 . This is a "HEALTH LINK INS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5132004 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 838915 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 109800 . This is a "HEALTH ALLIANCE INS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1729885 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com