Provider Demographics
NPI:1689822835
Name:FULTON, ANN MARIE (MSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:FULTON
Suffix:
Gender:F
Credentials:MSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 GLENNA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2719
Mailing Address - Country:US
Mailing Address - Phone:513-443-1700
Mailing Address - Fax:513-893-9888
Practice Address - Street 1:640 GLENNA DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2719
Practice Address - Country:US
Practice Address - Phone:513-443-1700
Practice Address - Fax:513-893-9888
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002668363LP0808X
IL209017744363LP0808X
OHAPRN.CNP.11485363LP0808X
OHCOA.11485-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0164488Medicaid