Provider Demographics
NPI:1306211537
Name:FULLERTON, ANGELICA FAYE (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELICA
Middle Name:FAYE
Last Name:FULLERTON
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 1:9300 DEWITT LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:850-452-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101281935208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice