Provider Demographics
NPI:1689141202
Name:FULTS, JILLIANE RENEE' (RN)
Entity Type:Individual
Prefix:
First Name:JILLIANE
Middle Name:RENEE'
Last Name:FULTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 LAKE TIMPSON RD
Mailing Address - Street 2:
Mailing Address - City:TIMPSON
Mailing Address - State:TX
Mailing Address - Zip Code:75975-9612
Mailing Address - Country:US
Mailing Address - Phone:936-332-3458
Mailing Address - Fax:
Practice Address - Street 1:503 LAKE TIMPSON RD
Practice Address - Street 2:
Practice Address - City:TIMPSON
Practice Address - State:TX
Practice Address - Zip Code:75975-9612
Practice Address - Country:US
Practice Address - Phone:936-332-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX839549163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse