Provider Demographics
NPI:1336787035
Name:FULTON, YOLANDA MONIQUE
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:MONIQUE
Last Name:FULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YOLANDA
Other - Middle Name:MONIQUE
Other - Last Name:DISHMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1094
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303
Mailing Address - Country:US
Mailing Address - Phone:901-497-0513
Mailing Address - Fax:
Practice Address - Street 1:711 PURDUVE AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:901-497-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR187523104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness