Provider Demographics
NPI:1609045343
Name:FULLER, LINDA MARIE (ANP, CDE)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:ANP, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 SWAN STREET
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:14048-9766
Mailing Address - Country:US
Mailing Address - Phone:716-366-7331
Mailing Address - Fax:716-363-5228
Practice Address - Street 1:701 SENECA ST STE 646C
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-1351
Practice Address - Country:US
Practice Address - Phone:716-995-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY369389-1163W00000X
NY306314363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY369389-1OtherNYS NURSING LICENSE