Provider Demographics
NPI:1053867572
Name:FULLER-NAVE, MARY K (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:FULLER-NAVE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:NAVE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13450 N MERIDIAN ST STE 145
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13450 N MERIDIAN ST STE 145
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1484
Practice Address - Country:US
Practice Address - Phone:317-338-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006575A208M00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300039160Medicaid
IN266180742Medicare PIN