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NPI Code Detail

MEDICARE: MRS. MARY FULLER DNP

MEDICARE: MRS. MARY FULLER DNP
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
12083P0901XPublic Health & General Preventive Medicine Physician209021513IL
2363LP2300XPrimary Care Nurse Practitioner209021513IL
3363L00000XNurse Practitioner209021513IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1497364053
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MARY FULLER DNP
Provider Business Mailing Address
First Line : 110 N BURR BLVD
Second Line :
City : KEWANEE
State : IL
Zip : 61443-2214
Country : US
Telephone Number : 309-852-0197
Fax Number : 309-854-5575
Provider Business Practice Location Address
First Line : 110 N BURR BLVD
Second Line :
City : KEWANEE
State : IL
Zip : 61443-2214
Country : US
Telephone Number : 309-852-0197
Fax Number : 309-854-5575
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/29/2020
Last Update Date : 08/04/2020

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