Provider Demographics
NPI:1508375338
Name:FULTON, MARSHALL HAVEN
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:HAVEN
Last Name:FULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PLEASANT RIDGE DR APT 109
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-2554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 SETON DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3232
Practice Address - Country:US
Practice Address - Phone:410-358-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR-127815163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse