Healthcare Provider Details

I. General information

NPI: 1780399907
Provider Name (Legal Business Name): STEPHANIE MARIE FULKS DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N RITTER AVE
INDIANAPOLIS IN
46219-3027
US

IV. Provider business mailing address

11110 WOODBURY DR
CARMEL IN
46033-3788
US

V. Phone/Fax

Practice location:
  • Phone: 317-918-3848
  • Fax:
Mailing address:
  • Phone: 317-918-3848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28229839A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71013487A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: