Provider Demographics
NPI:1144210527
Name:FULLER, CHERYL K (APRN, CDE)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:640 FLORMANN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4679
Practice Address - Country:US
Practice Address - Phone:605-755-3300
Practice Address - Fax:605-755-3129
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001051363L00000X
KY1058257173000000X
KY3003469363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000057119FOtherHUMANA - NMFMS
KY123833OtherSIHO - NMFMS
KY9094802OtherCIGNA - NMFMS
KY000000704718OtherANTHEM - NMFMS
KY50031950OtherPASSPORT/PASSPORT ADV - NMFMS
KY78008950Medicaid
IN200385950Medicaid
KY000057119FOtherHUMANA - NMFMS
KY123833OtherSIHO - NMFMS
KYP400040748Medicare PIN