Healthcare Provider Details

I. General information

NPI: 1639804529
Provider Name (Legal Business Name): MELISSA DAWN FULLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2022
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2207 ROCKFORD DR
CHIPLEY FL
32428-3004
US

IV. Provider business mailing address

9489 LEE ROAD 379
VALLEY AL
36854-6686
US

V. Phone/Fax

Practice location:
  • Phone: 334-524-1969
  • Fax:
Mailing address:
  • Phone: 234-524-1969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-112786
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11022480
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: