Provider Demographics
NPI:1356485015
Name:FULLER, FAITH (FNP)
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:2055 S FREMONT AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2206
Practice Address - Country:US
Practice Address - Phone:417-820-8099
Practice Address - Fax:417-820-8093
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO052926363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423774801Medicaid
MO423774801Medicaid
MO837303230Medicare PIN
MO000080676Medicare PIN