Provider Demographics
NPI:1174239545
Name:FULLEN, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FULLEN
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 1:314 HAMILTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6838
Mailing Address - Country:US
Mailing Address - Phone:423-557-4765
Mailing Address - Fax:
Practice Address - Street 1:7353 REEDY CREEK RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-1911
Practice Address - Country:US
Practice Address - Phone:423-534-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty