Provider Demographics
NPI:1013365659
Name:FULWILEY, REGINALD
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:FULWILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:318-331-3619
Mailing Address - Fax:601-510-9052
Practice Address - Street 1:229 WEST MAIN ST
Practice Address - Street 2:SUITE 12 3RD FL
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39350-0245
Practice Address - Country:US
Practice Address - Phone:318-331-3619
Practice Address - Fax:601-510-9052
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857836374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide