Provider Demographics
NPI:1700022159
Name:FULP, CANDY
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:
Last Name:FULP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 HONAKER AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-3065
Mailing Address - Country:US
Mailing Address - Phone:304-487-1551
Mailing Address - Fax:
Practice Address - Street 1:1403 HONAKER AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3065
Practice Address - Country:US
Practice Address - Phone:304-487-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51093163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013320Medicaid