Healthcare Provider Details

I. General information

NPI: 1467946277
Provider Name (Legal Business Name): JESSICA SWINK FULK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LEANNE SWINK

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 GILLMAN RD STE A
DENVER NC
28037-7925
US

IV. Provider business mailing address

9930 KINCEY AVE STE 165
HUNTERSVILLE NC
28078-6541
US

V. Phone/Fax

Practice location:
  • Phone: 704-659-7830
  • Fax: 877-881-8455
Mailing address:
  • Phone: 704-947-5005
  • Fax: 877-881-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08139
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: