Provider Demographics
NPI:1154356954
Name:FULLINGTON, ANN L (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:L
Last Name:FULLINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-9001
Mailing Address - Country:US
Mailing Address - Phone:715-804-7500
Mailing Address - Fax:
Practice Address - Street 1:3430 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-9001
Practice Address - Country:US
Practice Address - Phone:715-804-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH23735Medicare UPIN
WI34011300Medicaid