Provider Demographics
NPI:1568454783
Name:FULLER, URSULA L (APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:URSULA
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:MO
Practice Address - Zip Code:64776-9547
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0065665363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO003193OtherFAMILY HEALTH PARTNERS
MO428932016Medicaid
MO428932032Medicaid
MO428932016Medicaid
MO793824Medicare Oscar/Certification
MO003193OtherFAMILY HEALTH PARTNERS