Healthcare Provider Details

I. General information

NPI: 1942357306
Provider Name (Legal Business Name): PAMELA ANGEL FULTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 QUINCY ST NE
ALBUQUERQUE NM
87110-5021
US

IV. Provider business mailing address

1308 QUINCY ST NE
ALBUQUERQUE NM
87110-5021
US

V. Phone/Fax

Practice location:
  • Phone: 505-453-4727
  • Fax:
Mailing address:
  • Phone: 505-453-4727
  • Fax: 877-860-2279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP 00616
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP00616
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: