Healthcare Provider Details

I. General information

NPI: 1124347786
Provider Name (Legal Business Name): DIANNE LEE FULLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANNE LEE FULLER CLYDE FNP-C

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 S MAIN ST
SALT LAKE CITY UT
84115-4423
US

IV. Provider business mailing address

10 S 2000 E UNIVERSITY OF UTAH COLLEGE OF NURSING
SALT LAKE CITY UT
84112-5880
US

V. Phone/Fax

Practice location:
  • Phone: 801-910-3690
  • Fax:
Mailing address:
  • Phone: 801-582-5573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number308008-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: