Provider Demographics
NPI:1730680372
Name:FULLENKAMP, JOSHUA J (NP)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:J
Last Name:FULLENKAMP
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7588
Mailing Address - Fax:317-957-2749
Practice Address - Street 1:1100 MERCER AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2303
Practice Address - Country:US
Practice Address - Phone:260-724-2145
Practice Address - Fax:260-728-3852
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28194969A163W00000X
IN71007872A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse