Provider Demographics
NPI:1285221440
Name:FULLER, JEREMY WAYNE (FNP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:WAYNE
Last Name:FULLER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 OVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0218
Mailing Address - Country:US
Mailing Address - Phone:530-333-3821
Mailing Address - Fax:
Practice Address - Street 1:29632 HWY. 299 EAST
Practice Address - Street 2:
Practice Address - City:ROUND MOUNTAIN
Practice Address - State:CA
Practice Address - Zip Code:96084
Practice Address - Country:US
Practice Address - Phone:530-337-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015009363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily