Healthcare Provider Details

I. General information

NPI: 1407343411
Provider Name (Legal Business Name): MS. MICHELLE ANNE FULLMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W 10TH AVE
COLUMBUS OH
43210
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-3196
  • Fax: 614-293-4812
Mailing address:
  • Phone: 614-293-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.02037
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number326109
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: