Provider Demographics
NPI:1457492795
Name:FULLBRIGHT, GINA M (CNP)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:M
Last Name:FULLBRIGHT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6310
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-6310
Mailing Address - Country:US
Mailing Address - Phone:575-522-9793
Mailing Address - Fax:575-532-9019
Practice Address - Street 1:2520 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4907
Practice Address - Country:US
Practice Address - Phone:575-522-9793
Practice Address - Fax:575-532-9019
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR28306363LW0102X
NMCNP00547363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16574052Medicaid
NM416312YPD8Medicare PIN