Provider Demographics
NPI:1194600361
Name:FULLERTON, MATTHEW JOHN (STNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27137 STUART ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCKBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43149
Mailing Address - Country:US
Mailing Address - Phone:740-583-0902
Mailing Address - Fax:
Practice Address - Street 1:2445 COLUMBUS-LANCASTER RD NW
Practice Address - Street 2:LOT 475
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130
Practice Address - Country:US
Practice Address - Phone:740-277-6293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401984010717251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health