Provider Demographics
NPI:1245775428
Name:FULLER, MARY N (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:N
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-559-9423
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:106 W JOHN ROWAN BLVD STE E
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2636
Practice Address - Country:US
Practice Address - Phone:502-350-4799
Practice Address - Fax:502-350-4798
Is Sole Proprietor?:No
Enumeration Date:2016-12-27
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3010827363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner