Provider Demographics
NPI:1265025803
Name:FULTON, CYNTHIA HEINTZ (AGNP-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:HEINTZ
Last Name:FULTON
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:HEINTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4420 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7505
Mailing Address - Country:US
Mailing Address - Phone:919-784-3542
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018581363LG0600X, 363LA2200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program