Provider Demographics
NPI:1477020303
Name:CERVANTES-FULLMER, MARIA TERESA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:TERESA
Last Name:CERVANTES-FULLMER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741716
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3245 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7536
Practice Address - Country:US
Practice Address - Phone:208-227-2790
Practice Address - Fax:208-227-2735
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46717207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology