Healthcare Provider Details

I. General information

NPI: 1104285113
Provider Name (Legal Business Name): MRS. MATTIE FAYE FULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MATTIE FAYE WATERS RN

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 SAVANNAH RD
LEWES DE
19958-1462
US

IV. Provider business mailing address

424 SAVANNAH RD
LEWES DE
19958-1462
US

V. Phone/Fax

Practice location:
  • Phone: 302-645-3336
  • Fax: 302-645-0965
Mailing address:
  • Phone: 302-645-3336
  • Fax: 302-645-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberL1-0021469
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: