Provider Demographics
NPI:1598536062
Name:FULTZ, MADISON MIKAYLA (APRN)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:MIKAYLA
Last Name:FULTZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 CASSIDY DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3403
Mailing Address - Country:US
Mailing Address - Phone:937-561-8988
Mailing Address - Fax:
Practice Address - Street 1:21 E STATE ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4281
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0036486363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health