Healthcare Provider Details

I. General information

NPI: 1144049677
Provider Name (Legal Business Name): MACIE FULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7315 E FRONTAGE RD STE 140
MERRIAM KS
66204-1600
US

IV. Provider business mailing address

7315 E FRONTAGE RD STE 140
MERRIAM KS
66204-1600
US

V. Phone/Fax

Practice location:
  • Phone: 913-676-2370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number157302
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: