Healthcare Provider Details

I. General information

NPI: 1699881698
Provider Name (Legal Business Name): DAVID GLENN FULGHUM FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 E MAIN ST
FLIPPIN AR
72634-8668
US

IV. Provider business mailing address

806 E MAIN ST
FLIPPIN AR
72634-8668
US

V. Phone/Fax

Practice location:
  • Phone: 870-443-2266
  • Fax: 870-895-2164
Mailing address:
  • Phone: 870-453-2266
  • Fax: 870-895-2164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN7249
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003021
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2005012311
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: