Provider Demographics
NPI:1770268757
Name:FULCOMER, LOURDES SOFIA (FNP)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:SOFIA
Last Name:FULCOMER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13607-1391
Mailing Address - Country:US
Mailing Address - Phone:315-482-2511
Mailing Address - Fax:
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1391
Practice Address - Country:US
Practice Address - Phone:315-482-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY803858163W00000X
NY351959363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse