MEDICARE: TINA FULCHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	0024179418	VA

General Provider Information

NPI Number	:	1194341792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA FULCHER

Provider Business Mailing Address
First Line	:	13300 BURLEY RIDGE LN
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-7119
Country	:	US
Telephone Number	:	804-926-6092
Fax Number	:

Provider Business Practice Location Address
First Line	:	13300 BURLEY RIDGE LN
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-7119
Country	:	US
Telephone Number	:	804-926-6092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2020
Last Update Date	:	06/19/2020

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Directions to “ TINA FULCHER ” Practice Location

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