Healthcare Provider Details

I. General information

NPI: 1679648570
Provider Name (Legal Business Name): ASHLEY ELAINE FULLER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 OLD KENTUCKY TURNPIKE
CEDAR BLUFF VA
24609
US

IV. Provider business mailing address

276 GRANDVIEW DR
POUNDING MILL VA
24637-4182
US

V. Phone/Fax

Practice location:
  • Phone: 276-964-0555
  • Fax: 276-964-2999
Mailing address:
  • Phone: 276-963-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002066196
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: