Healthcare Provider Details

I. General information

NPI: 1689389249
Provider Name (Legal Business Name): KELLI FULTZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 HOSPITAL RD
CHILLICOTHEE OH
45601-9031
US

IV. Provider business mailing address

272 HOSPITAL RD
CHILLICOTHEE OH
45601-9031
US

V. Phone/Fax

Practice location:
  • Phone: 740-779-4598
  • Fax: 740-779-4599
Mailing address:
  • Phone: 740-779-4598
  • Fax: 740-779-4599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP.0033058
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: