Provider Demographics
NPI:1497050785
Name:FULCHER, EDWINA (LPN)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:
Last Name:FULCHER
Suffix:
Gender:F
Credentials:LPN
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 532
Mailing Address - Street 2:
Mailing Address - City:SAGAPONCK
Mailing Address - State:NY
Mailing Address - Zip Code:11962
Mailing Address - Country:US
Mailing Address - Phone:917-951-0580
Mailing Address - Fax:
Practice Address - Street 1:560 SAGG RD
Practice Address - Street 2:
Practice Address - City:SAGAPONCK
Practice Address - State:NY
Practice Address - Zip Code:11962
Practice Address - Country:US
Practice Address - Phone:917-951-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2140261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse