Provider Demographics
NPI:1003892167
Name:FULLER, JULIA DARLENE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JULIA
Middle Name:DARLENE
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JULIA
Other - Middle Name:DARLENE
Other - Last Name:DIMICK-FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:555 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2250
Mailing Address - Country:US
Mailing Address - Phone:717-544-7890
Mailing Address - Fax:717-544-7151
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-7890
Practice Address - Fax:717-544-7151
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN321584L367500000X
PARN-322584L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001513341Medicaid
PA001513341Medicaid
PA020950Medicare PIN