=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427795228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE M. FULLER PMPNP-BC, MSN, CNL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2022
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1655 N ARLINGTON HEIGHTS RD STE 200
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60004-3982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-342-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1655 N ARLINGTON HEIGHTS RD STE 200W
-----------------------------------------------------
City | ARLINGTON HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60004-3977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-263-0903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209027763
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------