1821519943 NPI number — JUDITH ANN FULTON FNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821519943 NPI number — JUDITH ANN FULTON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULTON
Provider First Name:
JUDITH
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FULTON
Provider Other First Name:
JUDITH
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821519943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14575 STATE ROUTE 41
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST UNION
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45693-9744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-544-2269
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 WAYNE FRYE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45144-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-549-1270
Provider Business Practice Location Address Fax Number:
937-549-1286
Provider Enumeration Date:
06/28/2017

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: 363LF0000X , with the licence number:  APRN.CNP.020752 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0249089 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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