Provider Demographics
NPI:1487630463
Name:HART-FULLER, PATRICIA (WHCNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:HART-FULLER
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15111 TWELVE OAKS CENTER DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5201
Practice Address - Country:US
Practice Address - Phone:952-993-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1145692363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health