Provider Demographics
NPI:1194341792
Name:FULCHER, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FULCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 BURLEY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7119
Mailing Address - Country:US
Mailing Address - Phone:804-926-6092
Mailing Address - Fax:
Practice Address - Street 1:13300 BURLEY RIDGE LN
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-7119
Practice Address - Country:US
Practice Address - Phone:804-926-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179418363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology