Healthcare Provider Details

I. General information

NPI: 1447872692
Provider Name (Legal Business Name): MARY ELIZABETH FULLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR STE C
DECATUR TX
76234-3844
US

IV. Provider business mailing address

779 GRAPEVINE HWY
HURST TX
76054-2805
US

V. Phone/Fax

Practice location:
  • Phone: 940-626-2110
  • Fax:
Mailing address:
  • Phone: 817-428-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP145920
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: