Provider Demographics
NPI:1699014894
Name:FULFORD, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:FULFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:ECKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5709
Mailing Address - Country:US
Mailing Address - Phone:812-237-1161
Mailing Address - Fax:
Practice Address - Street 1:3901 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5709
Practice Address - Country:US
Practice Address - Phone:812-237-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002239A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered