Provider Demographics
NPI:1164601225
Name:FULLWOOD, MARCIA DOREEN (ANP/GNP)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:DOREEN
Last Name:FULLWOOD
Suffix:
Gender:F
Credentials:ANP/GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 WATSON AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-3303
Mailing Address - Country:US
Mailing Address - Phone:862-520-2371
Mailing Address - Fax:
Practice Address - Street 1:87 WATSON AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3303
Practice Address - Country:US
Practice Address - Phone:862-520-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304754-1363LA2200X
NYF340688-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology