Provider Demographics
NPI:1629848098
Name:FULFER, ELI JACOB
Entity Type:Individual
Prefix:
First Name:ELI
Middle Name:JACOB
Last Name:FULFER
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 1:3109 S 28TH PL APT 1
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4720
Mailing Address - Country:US
Mailing Address - Phone:479-530-9754
Mailing Address - Fax:
Practice Address - Street 1:3109 S 28TH PL APT 1
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-4720
Practice Address - Country:US
Practice Address - Phone:479-530-9754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR213657163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse