Provider Demographics
NPI:1548748486
Name:FULLEN, WHITNEY ILLENE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:WHITNEY
Middle Name:ILLENE
Last Name:FULLEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21016 CHEYENNE TRL
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-6694
Mailing Address - Country:US
Mailing Address - Phone:276-685-3292
Mailing Address - Fax:
Practice Address - Street 1:105 WESTWOOD CMN
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-2031
Practice Address - Country:US
Practice Address - Phone:276-326-2686
Practice Address - Fax:276-326-2249
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457369100Medicaid
VA1598725285Medicaid