Provider Demographics
NPI:1427047026
Name:FULK, TARA C
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:FULK
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 1:112 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:VA
Mailing Address - Zip Code:22812-1611
Mailing Address - Country:US
Mailing Address - Phone:540-828-6443
Mailing Address - Fax:540-828-6583
Practice Address - Street 1:112 N RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1611
Practice Address - Country:US
Practice Address - Phone:540-828-6443
Practice Address - Fax:540-828-6583
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194031OtherANTHEM PROVIDER NUMBER
VA194031OtherANTHEM PROVIDER NUMBER