Healthcare Provider Details

I. General information

NPI: 1912334095
Provider Name (Legal Business Name): ALLISON N FULLERTON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 S BALDWIN AVE
ARCADIA FL
34266-3387
US

IV. Provider business mailing address

34 S BALDWIN AVE
ARCADIA FL
34266-3387
US

V. Phone/Fax

Practice location:
  • Phone: 863-491-7580
  • Fax: 863-491-7584
Mailing address:
  • Phone: 863-491-7580
  • Fax: 863-491-7584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5162961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: