Provider Demographics
NPI:1639916182
Name:FULGHAM, CARLEY (NP)
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:FULGHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1286 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:ETHELSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35461-2939
Mailing Address - Country:US
Mailing Address - Phone:205-399-8240
Mailing Address - Fax:
Practice Address - Street 1:5713 U.S. 45 ALTERNATE SOUTH
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-0414
Practice Address - Country:US
Practice Address - Phone:662-854-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner