Healthcare Provider Details

I. General information

NPI: 1790807824
Provider Name (Legal Business Name): JESSICA FULLER-HINES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA FULLER

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E RICH BLVD
ELIZABETH CITY NC
27909-5518
US

IV. Provider business mailing address

135 E RICH BLVD
ELIZABETH CITY NC
27909-5518
US

V. Phone/Fax

Practice location:
  • Phone: 252-333-1277
  • Fax: 252-333-1877
Mailing address:
  • Phone: 252-333-1277
  • Fax: 252-333-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2007-00519
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: