Provider Demographics
NPI:1366587990
Name:FULLWOOD, KAREN R (HIS)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:R
Last Name:FULLWOOD
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4134 E JOPPA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-2277
Mailing Address - Country:US
Mailing Address - Phone:410-256-1006
Mailing Address - Fax:410-256-0088
Practice Address - Street 1:4134 E JOPPA RD STE 101
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-2277
Practice Address - Country:US
Practice Address - Phone:410-256-1006
Practice Address - Fax:410-256-0088
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02431237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD421CCLOtherCAREFIRST BC/BS