Provider Demographics
NPI:1508308610
Name:FULP, NANETTE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:NICOLE
Last Name:FULP
Suffix:
Gender:F
Credentials:PA-C
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-759-7596
Mailing Address - Fax:336-759-3652
Practice Address - Street 1:1995 BETHABARA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3375
Practice Address - Country:US
Practice Address - Phone:336-759-7596
Practice Address - Fax:336-759-3652
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06840363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant