Basic Information
| Provider Information | |||||||||
| NPI: | 1316451248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 TECH CENTER DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432301987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149444800 | ||||||||
| FaxNumber: | 6149444750 | ||||||||
| Practice Location | |||||||||
| Address1: | 269 PORTLAND WAY S | ||||||||
| Address2: | |||||||||
| City: | GALION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448332312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194684841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2017 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.021791 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0180847 | 05 | OH | MEDICAID |