Healthcare Provider Details

I. General information

NPI: 1619974227
Provider Name (Legal Business Name): NONA P FULK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NONA P PAWLAK

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E LOCUST ST
OLNEY IL
62450-2553
US

IV. Provider business mailing address

1300 FRANKLIN AVE STE 330
NORMAL IL
61761-4204
US

V. Phone/Fax

Practice location:
  • Phone: 618-392-9520
  • Fax: 618-395-5117
Mailing address:
  • Phone: 309-808-0940
  • Fax: 309-808-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036096101
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: