MEDICARE: MS. CHERYL A FULLER APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209008363	IL

General Provider Information

NPI Number	:	1376851410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHERYL A FULLER APN

Provider Business Mailing Address
First Line	:	PO BOX 277
Second Line	:
City	:	DONGOLA
State	:	IL
Zip	:	62926-0277
Country	:	US
Telephone Number	:	618-827-3545
Fax Number	:	618-827-4891

Provider Business Practice Location Address
First Line	:	318 US HIGHWAY 51 N
Second Line	:
City	:	DONGOLA
State	:	IL
Zip	:	62926-1103
Country	:	US
Telephone Number	:	618-827-3545
Fax Number	:	618-827-4891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	04/25/2016

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