Provider Demographics
NPI:1376201335
Name:FULKERSON, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FULKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-4544
Mailing Address - Country:US
Mailing Address - Phone:304-995-4000
Mailing Address - Fax:
Practice Address - Street 1:319 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-4544
Practice Address - Country:US
Practice Address - Phone:304-995-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant