=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598275687
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAVEN FULGHAM FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2017
-----------------------------------------------------
Last Update Date | 10/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5818 HARBOUR VIEW BLVD STE 240
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23435-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-483-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1216 HAMPTON BLVD APT 4
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23517-1855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-285-1826
-----------------------------------------------------
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 | 0024175269
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------