Provider Demographics
NPI:1417560194
Name:FULLER, VANESSA RENEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:RENEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 HOSPITAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4556
Mailing Address - Country:US
Mailing Address - Phone:707-462-7900
Mailing Address - Fax:707-462-7947
Practice Address - Street 1:275 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4531
Practice Address - Country:US
Practice Address - Phone:707-462-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily