Provider Demographics
NPI:1023601069
Name:FULTZ, SHANNON (APRN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-4733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-4733
Practice Address - Country:US
Practice Address - Phone:603-765-1431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02454363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAPRN02454OtherSTATE