Healthcare Provider Details

I. General information

NPI: 1659655017
Provider Name (Legal Business Name): ELISA J. FULLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8035 N 85TH WAY
SCOTTSDALE AZ
85258-4321
US

IV. Provider business mailing address

8035 N 85TH WAY
SCOTTSDALE AZ
85258-4321
US

V. Phone/Fax

Practice location:
  • Phone: 480-304-9234
  • Fax: 480-907-2011
Mailing address:
  • Phone: 480-304-9234
  • Fax: 480-907-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number25928
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: