Provider Demographics
NPI:1245803345
Name:FULLER, JENNIFER LEE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1302 S LYNN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-6860
Mailing Address - Country:US
Mailing Address - Phone:580-286-3993
Mailing Address - Fax:580-286-3967
Practice Address - Street 1:1302 S LYNN LN
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-6860
Practice Address - Country:US
Practice Address - Phone:580-286-3993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK204314363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner