Provider Demographics
NPI:1760433569
Name:FULMER, KATRINA E (CRNA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:E
Last Name:FULMER
Suffix:
Gender:F
Credentials:CRNA
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 182255
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43218-2255
Mailing Address - Country:US
Mailing Address - Phone:614-430-5723
Mailing Address - Fax:
Practice Address - Street 1:4665 DOUGLAS CIR NW
Practice Address - Street 2:SUITE 101
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3673
Practice Address - Country:US
Practice Address - Phone:330-499-5700
Practice Address - Fax:330-498-4229
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN148264367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000135932OtherANTHEM
OH0751557Medicaid
000000135932OtherANTHEM