Provider Demographics
NPI:1699881698
Name:FULGHUM, DAVID GLENN (FNP-BC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:GLENN
Last Name:FULGHUM
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLIPPIN
Mailing Address - State:AR
Mailing Address - Zip Code:72634-8668
Mailing Address - Country:US
Mailing Address - Phone:870-453-2266
Mailing Address - Fax:870-895-2164
Practice Address - Street 1:806 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FLIPPIN
Practice Address - State:AR
Practice Address - Zip Code:72634-8668
Practice Address - Country:US
Practice Address - Phone:870-443-2266
Practice Address - Fax:870-895-2164
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN7249363LF0000X
ARA003021363LF0000X
MO2005012311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A520Medicare PIN
S57281Medicare UPIN