Provider Demographics
NPI:1598508640
Name:FULLENWIDER, CARMELLA L (AG-PCNP-BC)
Entity type:Individual
Prefix:
First Name:CARMELLA
Middle Name:L
Last Name:FULLENWIDER
Suffix:
Gender:F
Credentials:AG-PCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:541-278-4332
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:645 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1502
Practice Address - Country:US
Practice Address - Phone:541-389-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10027848363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care