Provider Demographics
NPI:1467675306
Name:HENRY, MACON FULIAR (APRN)
Entity Type:Individual
Prefix:
First Name:MACON
Middle Name:FULIAR
Last Name:HENRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:C
Other - Last Name:FULIAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2490 PINE DR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9273
Mailing Address - Country:US
Mailing Address - Phone:415-726-8971
Mailing Address - Fax:
Practice Address - Street 1:2901 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1851
Practice Address - Country:US
Practice Address - Phone:360-788-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX705159163WC0200X
CA95014151363LA2100X
TXAP144838363LA2100X
WAAP61088966363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2172703Medicaid