Provider Demographics
NPI:1770515728
Name:FULK, KIMOTHY ANN (APN NP C)
Entity type:Individual
Prefix:MRS
First Name:KIMOTHY
Middle Name:ANN
Last Name:FULK
Suffix:
Gender:F
Credentials:APN NP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-0516
Mailing Address - Country:US
Mailing Address - Phone:618-943-2609
Mailing Address - Fax:618-943-6409
Practice Address - Street 1:11020 STATE ROUTE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-3379
Practice Address - Country:US
Practice Address - Phone:618-943-2609
Practice Address - Fax:618-943-6409
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005713363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376006178007Medicaid
IL731354OtherHEALTH LINK INS
IL5132004OtherBCBS
838915OtherUNITED HEALTHCARE
IL109800OtherHEALTH ALLIANCE INS
1729885OtherFIRST HEALTH
Q56976Medicare UPIN
IL143951Medicare ID - Type Unspecified
IL376006178007Medicaid