Healthcare Provider Details

I. General information

NPI: 1821696196
Provider Name (Legal Business Name): LACREASHA FULLARD CRNP-PMH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 08/08/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9649 BELAIR RD STE 104
NOTTINGHAM MD
21236-1117
US

IV. Provider business mailing address

9649 BELAIR RD STE 104
NOTTINGHAM MD
21236-1117
US

V. Phone/Fax

Practice location:
  • Phone: 410-529-1309
  • Fax: 410-529-1005
Mailing address:
  • Phone: 410-529-1309
  • Fax: 410-529-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR219476
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: