Provider Demographics
NPI:1457010381
Name:FULLER, JONALYN PASCUA (NP)
Entity Type:Individual
Prefix:
First Name:JONALYN
Middle Name:PASCUA
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 S FREMONT AVE STE 3300
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2246
Mailing Address - Country:US
Mailing Address - Phone:417-820-5200
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE STE 3300
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2246
Practice Address - Country:US
Practice Address - Phone:417-820-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015021422163W00000X
MO2021043723363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse