Provider Demographics
NPI:1467113852
Name:FULLMER, MELANIE JEAN
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:JEAN
Last Name:FULLMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 CLAY EDWARDS DR STE 520
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3274
Mailing Address - Country:US
Mailing Address - Phone:816-691-5198
Mailing Address - Fax:816-346-7095
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 520
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3274
Practice Address - Country:US
Practice Address - Phone:816-691-5198
Practice Address - Fax:816-346-7095
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021051080163WC0200X
MO2022004714363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine