Healthcare Provider Details

I. General information

NPI: 1497659064
Provider Name (Legal Business Name): ELIZABETH FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH DIVERS

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 3RD ST SW
ROANOKE VA
24016-4611
US

IV. Provider business mailing address

191 HAZELRIDGE LN
BOONES MILL VA
24065-4677
US

V. Phone/Fax

Practice location:
  • Phone: 540-685-2718
  • Fax: 540-779-9958
Mailing address:
  • Phone: 540-685-2718
  • Fax: 540-779-9958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001226905
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: