Provider Demographics
NPI:1932734803
Name:FULTON, SHANE AMOUR (CNA , MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:AMOUR
Last Name:FULTON
Suffix:
Gender:F
Credentials:CNA , MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 N 16TH ST APT D204
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-1711
Mailing Address - Country:US
Mailing Address - Phone:623-986-6877
Mailing Address - Fax:
Practice Address - Street 1:6131 N 16TH ST APT D204
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-1711
Practice Address - Country:US
Practice Address - Phone:623-986-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ374U00000X
AZCNA1000056885376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZNONEOtherNONE