Provider Demographics
NPI:1629444666
Name:FULLER, JOSELYN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JOSELYN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:JOSELYN
Other - Middle Name:
Other - Last Name:LONDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 96398
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-6398
Mailing Address - Country:US
Mailing Address - Phone:800-962-3303
Mailing Address - Fax:405-609-1466
Practice Address - Street 1:3580 W 9000 SOUTH
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8899
Practice Address - Country:US
Practice Address - Phone:801-561-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-13
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7327150-4405363LF0000X
UT7327150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily