Provider Demographics
NPI:1497176911
Name:FULLER, MARY-FAITH (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY-FAITH
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12176 S 1000 E
Mailing Address - Street 2:STE G
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9734
Mailing Address - Country:US
Mailing Address - Phone:801-523-3030
Mailing Address - Fax:801-523-3033
Practice Address - Street 1:12176 S 1000 E
Practice Address - Street 2:STE G
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9734
Practice Address - Country:US
Practice Address - Phone:801-523-3030
Practice Address - Fax:801-523-3033
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7737232-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics