Healthcare Provider Details

I. General information

NPI: 1891726337
Provider Name (Legal Business Name): NANCY MARIE FULLER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD VA ROSEBURG HEALTHCARE SYSTEM
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

913 NW GARDEN VALLEY BLVD VA ROSEBURG HEALTHCARE SYSTEM
ROSEBURG OR
97471-6523
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax: 541-440-1230
Mailing address:
  • Phone: 541-440-1000
  • Fax: 541-440-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209-003019
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number201050069NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: