=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316272016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JODY FULTON ALEXANDER PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2009
-----------------------------------------------------
Last Update Date | 11/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 RICHARD DR
-----------------------------------------------------
City | GLENSHAW
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15116-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-625-3171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 848 PO BOX 848
-----------------------------------------------------
City | MARS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16046-0848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-625-3171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP010560
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------