Provider Demographics
NPI:1386682300
Name:FULLER WIESNER, DEIRDRE (APRN)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:FULLER WIESNER
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 1:19 FARRINGTON CORNER RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINTON
Mailing Address - State:NH
Mailing Address - Zip Code:03229-2020
Mailing Address - Country:US
Mailing Address - Phone:603-228-7575
Mailing Address - Fax:603-228-7585
Practice Address - Street 1:19 FARRINGTON CORNER RD
Practice Address - Street 2:
Practice Address - City:HOPKINTON
Practice Address - State:NH
Practice Address - Zip Code:03229-2020
Practice Address - Country:US
Practice Address - Phone:603-228-7575
Practice Address - Fax:603-228-7585
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH344212303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHS32346Medicare UPIN