Provider Demographics
NPI:1881204899
Name:FULTON, WANDA KAY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:KAY
Last Name:FULTON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9023 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:SC
Mailing Address - Zip Code:29061-9540
Mailing Address - Country:US
Mailing Address - Phone:803-978-1848
Mailing Address - Fax:803-978-1852
Practice Address - Street 1:3041 OLD EASTOVER RD
Practice Address - Street 2:
Practice Address - City:EASTOVER
Practice Address - State:SC
Practice Address - Zip Code:29044-8303
Practice Address - Country:US
Practice Address - Phone:803-353-8741
Practice Address - Fax:803-353-8789
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily