MEDICARE: LAURA ELIZABETH FULBROOK

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	363LA2200X	Adult Health Nurse Practitioner	53-78475-092	KS

General Provider Information

NPI Number	:	1376012849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA ELIZABETH FULBROOK

Provider Business Mailing Address
First Line	:	1358 S SIERRA HILLS ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67230-7548
Country	:	US
Telephone Number	:	617-699-2960
Fax Number	:

Provider Business Practice Location Address
First Line	:	1358 S SIERRA HILLS ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67230-7548
Country	:	US
Telephone Number	:	617-699-2960
Fax Number	:

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

Provider Enumeration Date	:	11/14/2018
Last Update Date	:	03/25/2019

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