Healthcare Provider Details

I. General information

NPI: 1770268757
Provider Name (Legal Business Name): LOURDES SOFIA FULCOMER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606A BOLL WEEVIL CIR
ENTERPRISE AL
36330-2734
US

IV. Provider business mailing address

606A BOLL WEEVIL CIR
ENTERPRISE AL
36330-2734
US

V. Phone/Fax

Practice location:
  • Phone: 334-475-2462
  • Fax:
Mailing address:
  • Phone: 334-475-2462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3-002843
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number41315
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number315959
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number803858
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number185414
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: