Basic Information
| Provider Information | |||||||||
| NPI: | 1467691170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | DONITA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHILLIPS | ||||||||
| OtherFirstName: | DONITA | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1140 W 500 S | ||||||||
| Address2: | PO BOX 1908 | ||||||||
| City: | VERNAL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840782914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357896300 | ||||||||
| FaxNumber: | 4357896325 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 W 500 S | ||||||||
| Address2: | |||||||||
| City: | VERNAL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840782914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357896300 | ||||||||
| FaxNumber: | 4357896325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2009 | ||||||||
| LastUpdateDate: | 02/19/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 660982 | TX | Y | Nursing Service Providers | Registered Nurse |
No ID Information.