Healthcare Provider Details

I. General information

NPI: 1750832176
Provider Name (Legal Business Name): AMANDA FULTZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SOUTH QUEEN STREET BERKELEY COUNTY BOARD OF ED
MARTINSBURG WV
25401
US

IV. Provider business mailing address

401 SOUTH QUEEN STREET BERKELEY COUNTY BOARD OF ED
MARTINSBURG WV
25401
US

V. Phone/Fax

Practice location:
  • Phone: 304-267-3595
  • Fax: 304-267-3599
Mailing address:
  • Phone: 304-267-3595
  • Fax: 304-267-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number85485
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: