Basic Information
| Provider Information | |||||||||
| NPI: | 1114445897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | COPE | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR FL HP2 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 DAVIS ST | ||||||||
| Address2: | |||||||||
| City: | BLACKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240607008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409610218 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2017 | ||||||||
| LastUpdateDate: | 11/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 0024175078 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | 0024175078 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.