Provider Demographics
NPI:1124563176
Name:FULMER, MARY ALICE (DNP, ARNP, FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:FULMER
Suffix:
Gender:F
Credentials:DNP, ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 ALTON RD
Mailing Address - Street 2:4 MAIN
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2948
Mailing Address - Country:US
Mailing Address - Phone:305-674-2340
Mailing Address - Fax:305-674-2351
Practice Address - Street 1:4300 ALTON RD
Practice Address - Street 2:4 MAIN
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2948
Practice Address - Country:US
Practice Address - Phone:305-674-2340
Practice Address - Fax:305-674-2351
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9331488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily