=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619457256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE MOBLEY FULLUM CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2018
-----------------------------------------------------
Last Update Date | 08/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 LEM MORRISON DRIVE
-----------------------------------------------------
City | AUBURN UNIVERSITY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36849-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-844-6126
-----------------------------------------------------
Fax | 334-844-6126
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 839 MILLERS POINT RD
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36830-7628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-703-2401
-----------------------------------------------------
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 | 1-049036
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------