Healthcare Provider Details

I. General information

NPI: 1164337358
Provider Name (Legal Business Name): MELANIE SUE FULFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HIGHWAY 361, BUILDING 2516 MEDICAL
CRANE IN
47522
US

IV. Provider business mailing address

300 HIGHWAY 361, BUILDING 2516 MEDICAL
CRANE IN
47522
US

V. Phone/Fax

Practice location:
  • Phone: 812-854-1220
  • Fax: 812-854-1339
Mailing address:
  • Phone: 812-854-1220
  • Fax: 812-854-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number28162777C
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: