Healthcare Provider Details

I. General information

NPI: 1891345674
Provider Name (Legal Business Name): JENNIFER FULLEM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TWIN SPRINGS RD
HALETHORPE MD
21227-3553
US

IV. Provider business mailing address

45 4TH ST
NEW FREEDOM PA
17349-9742
US

V. Phone/Fax

Practice location:
  • Phone: 410-443-8874
  • Fax:
Mailing address:
  • Phone: 443-465-0155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR191487
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR191487
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: