Provider Demographics
NPI:1720411762
Name:FULTON, KATHERINE ALLGOOD (NNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ALLGOOD
Last Name:FULTON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320039
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-0039
Mailing Address - Country:US
Mailing Address - Phone:601-957-7345
Mailing Address - Fax:769-251-5924
Practice Address - Street 1:5 RIVER BEND PL
Practice Address - Street 2:SUITE C
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7618
Practice Address - Country:US
Practice Address - Phone:601-957-7345
Practice Address - Fax:769-251-5429
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR880059363LN0005X, 363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01955831Medicaid
MS01955831Medicaid
313768YJ5DMedicare PIN