1760433569 NPI number — KATRINA E FULMER CRNA

Table of content: KATRINA E FULMER CRNA (NPI 1760433569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760433569 NPI number — KATRINA E FULMER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULMER
Provider First Name:
KATRINA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1760433569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 182255
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43218-2255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-430-5723
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4665 DOUGLAS CIR NW
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44718-3673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-499-5700
Provider Business Practice Location Address Fax Number:
330-498-4229
Provider Enumeration Date:
05/15/2006

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: 367500000X , with the licence number:  RN148264 , 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: 000000135932 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0751557 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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