Provider Demographics
NPI:1023666146
Name:FULMORE, NANCY (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:FULMORE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:APPADURAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6622 N 91ST AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3358
Practice Address - Street 1:6553 E BAYWOOD AVE STE 205
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1754
Practice Address - Country:US
Practice Address - Phone:480-626-2020
Practice Address - Fax:480-626-2022
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ231655363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ586587Medicaid