Provider Demographics
NPI:1790807824
Name:FULLER-HINES, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FULLER-HINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 E RICH BLVD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5518
Mailing Address - Country:US
Mailing Address - Phone:252-333-1277
Mailing Address - Fax:252-333-1877
Practice Address - Street 1:135 E RICH BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5518
Practice Address - Country:US
Practice Address - Phone:252-333-1277
Practice Address - Fax:252-333-1877
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00519208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907327Medicaid
NC5907327Medicaid
NC6745110001Medicare NSC