Healthcare Provider Details

I. General information

NPI: 1598508640
Provider Name (Legal Business Name): CARMELLA L FULLENWIDER AG-PCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 NW 4TH ST
REDMOND OR
97756-1502
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-7741
  • Fax:
Mailing address:
  • Phone: 541-278-4332
  • Fax: 541-278-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number10027848
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: