MEDICARE: JESSICA ELIZABETH FULLER RN

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	163W00000X	Registered Nurse	RN9543828	FL
2	163W00000X	Registered Nurse	819891	NY

General Provider Information

NPI Number	:	1801695739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ELIZABETH FULLER RN

Provider Business Mailing Address
First Line	:	15 COON RD
Second Line	:
City	:	ARGYLE
State	:	NY
Zip	:	12809-1104
Country	:	US
Telephone Number	:	518-683-0466
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 COON RD
Second Line	:
City	:	ARGYLE
State	:	NY
Zip	:	12809-1104
Country	:	US
Telephone Number	:	518-683-0466
Fax Number	:

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

Provider Enumeration Date	:	03/12/2025
Last Update Date	:	03/12/2025

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