Healthcare Provider Details

I. General information

NPI: 1548894256
Provider Name (Legal Business Name): KAREN RENEE FULLER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S POLLARD ST
VINTON VA
24179-2502
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 625
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-983-6700
  • Fax:
Mailing address:
  • Phone: 540-224-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001205224
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: