MEDICARE: HETTER ELIZABETH FULLER FNP

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	207Q00000X	Family Medicine Physician	236499	AZ

General Provider Information

NPI Number	:	1386278554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HETTER ELIZABETH FULLER FNP

Provider Business Mailing Address
First Line	:	634 W CATCLAW ST
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85233-6802
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 W RAY RD STE 3
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-3552
Country	:	US
Telephone Number	:	480-626-6318
Fax Number	:

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

Provider Enumeration Date	:	02/26/2020
Last Update Date	:	02/26/2021

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