Healthcare Provider Details

I. General information

NPI: 1861474207
Provider Name (Legal Business Name): DEBORAH JOAN FULLER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MUNICIPAL WAY
EDGEWOOD NM
87015
US

IV. Provider business mailing address

2001 CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4592
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-3406
  • Fax: 505-286-3329
Mailing address:
  • Phone: 505-281-3406
  • Fax: 505-286-3329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR42788
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: