Healthcare Provider Details

I. General information

NPI: 1265152995
Provider Name (Legal Business Name): ELIZABETH ANN FULLNER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH ANN FULLNER RDH

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1897 134TH RD
OSCEOLA NE
68651-4891
US

IV. Provider business mailing address

120 W WASHINGTON ST
SHELBY NE
68662-5651
US

V. Phone/Fax

Practice location:
  • Phone: 308-883-6510
  • Fax:
Mailing address:
  • Phone: 308-883-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2919
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: