Healthcare Provider Details

I. General information

NPI: 1194600361
Provider Name (Legal Business Name): MATTHEW JOHN FULLERTON STNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2025
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 COLUMBUS-LANCASTER RD NW LOT 475
LANCASTER OH
43130
US

IV. Provider business mailing address

27137 STUART ROAD
ROCKBRIDGE OH
43149
US

V. Phone/Fax

Practice location:
  • Phone: 740-277-6293
  • Fax:
Mailing address:
  • Phone: 740-583-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number401984010717
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: