Provider Demographics
NPI:1073105474
Name:FULLER, MEGAN JOY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:JOY
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 JACKSON PARK CV
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7868
Mailing Address - Country:US
Mailing Address - Phone:501-259-5458
Mailing Address - Fax:
Practice Address - Street 1:205 JACKSON PARK CV
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7868
Practice Address - Country:US
Practice Address - Phone:501-259-5458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR081670163W00000X
AR214341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse