Healthcare Provider Details

I. General information

NPI: 1578880647
Provider Name (Legal Business Name): TERESA FULLEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 HOSPITAL AVE
MARION VA
24354-3157
US

IV. Provider business mailing address

PO BOX 729
SALTVILLE VA
24370-0729
US

V. Phone/Fax

Practice location:
  • Phone: 276-783-8185
  • Fax: 276-783-5030
Mailing address:
  • Phone: 276-496-4492
  • Fax: 276-496-4839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0001138223
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number0024168776
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024168776
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: