=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376724542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH FULFORD ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2007
-----------------------------------------------------
Last Update Date | 06/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 SW RANGE AVE SUITE - C
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-973-2252
-----------------------------------------------------
Fax | 855-531-6313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 289 SW RANGE AVE SUITE - C
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-973-2252
-----------------------------------------------------
Fax | 855-531-6313
-----------------------------------------------------
=====================================================
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 | 2693972
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------