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General NPI Number Information
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NPI Number | 1598508640
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Entity Type | Individual
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Provider Name | CARMELLA L FULLENWIDER AG-PCNP-BC
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Gender | Female
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Dates
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Enumeration Date | 06/17/2024
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Last Update Date | 06/28/2024
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Provider Practice Location Address
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Address Line | 645 NW 4TH ST
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City | REDMOND
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State | OR
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Zip | 97756-1502
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Country | US
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Telephone | 541-389-7741
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1517
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City | PENDLETON
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State | OR
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Zip | 97801-0410
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Country | US
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Telephone | 541-278-4332
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Fax | 541-278-8349
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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 | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 10027848
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License Number State | OR
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