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General NPI Number Information
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NPI Number | 1336787035
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Entity Type | Individual
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Provider Name | YOLANDA MONIQUE FULTON
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Gender | Female
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Dates
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Enumeration Date | 12/13/2019
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Last Update Date | 12/13/2019
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Provider Practice Location Address
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Address Line | 711 PURDUVE AVE
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City | WEST MEMPHIS
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State | AR
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Zip | 72301
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Country | US
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Telephone | 901-497-0513
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 1094
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City | WEST MEMPHIS
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State | AR
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Zip | 72303
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Country | US
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Telephone | 901-497-0513
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | 18752
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License Number State | AR
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