MEDICARE: MISS CONNIE ANN FULTON LPN

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	164W00000X	Licensed Practical Nurse	280482-1	NY

General Provider Information

NPI Number	:	1477881191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CONNIE ANN FULTON LPN

Provider Business Mailing Address
First Line	:	PO BOX 312
Second Line	:
City	:	MADISON
State	:	NY
Zip	:	13402-0312
Country	:	US
Telephone Number	:	315-368-4583
Fax Number	:

Provider Business Practice Location Address
First Line	:	3548 SOUTH ST MADISON
Second Line	:
City	:	MADISON 13402
State	:	NY
Zip	:	13402
Country	:	US
Telephone Number	:	315-368-4583
Fax Number	:

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

Provider Enumeration Date	:	11/19/2009
Last Update Date	:	11/19/2009

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