Provider Demographics
NPI:1730652041
Name:FULGHAM, TAYLOR ROSE (CNA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ROSE
Last Name:FULGHAM
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 SPRINGFIELD RD APT 8
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-6578
Mailing Address - Country:US
Mailing Address - Phone:309-807-7347
Mailing Address - Fax:
Practice Address - Street 1:1708 SPRINGFIELD RD APT 8
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-6578
Practice Address - Country:US
Practice Address - Phone:309-807-7347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide