Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 231655 | AZ |
NPI | 1023666146 |
---|---|
Provider Name | Nancy Fulmore |
First Address | Glendale, AZ 85305-2569 |
Second Address | Mesa, AZ 85206-1754 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2019 |
Last Update Date | 19/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
586587 | (05) | AZ |