Provider Demographics
NPI:1235514258
Name:FULLER, ASHLEY (ARNP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:MUSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-336-3125
Practice Address - Street 1:925 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-5726
Practice Address - Country:US
Practice Address - Phone:563-336-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-124228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1932193224Medicaid
ILPENDINGMedicaid
IA1932193224Medicaid