=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962596536
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA KAY FULLER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 08/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E VETERANS ST
-----------------------------------------------------
City | TOMAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54660-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-372-3971
-----------------------------------------------------
Fax | 608-374-8408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | S4259 CRAWFORD ST.
-----------------------------------------------------
City | BARABOO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53913-9118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-963-1090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 2571-033
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------