Healthcare Provider Details

I. General information

NPI: 1871371146
Provider Name (Legal Business Name): MELISSA J FULLER APRN, AGCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 ARAPAHOE AVE
BOULDER CO
80303-1131
US

IV. Provider business mailing address

4079 LONGHORN DR
LAFAYETTE CO
80026-9634
US

V. Phone/Fax

Practice location:
  • Phone: 303-415-7000
  • Fax:
Mailing address:
  • Phone: 303-524-4507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License NumberRN.0186597
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberAPN.10000013-CNS
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: