Healthcare Provider Details

I. General information

NPI: 1083818389
Provider Name (Legal Business Name): REBECCA BALDWIN FULLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MADDEX DR
SHEPHERDSTOWN WV
25443-4305
US

IV. Provider business mailing address

44035 RIVERSIDE PKWY STE 300
LEESBURG VA
20176-8260
US

V. Phone/Fax

Practice location:
  • Phone: 304-876-9422
  • Fax:
Mailing address:
  • Phone: 703-554-6800
  • Fax: 703-724-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number304631
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024168084
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number120365
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: