Provider Demographics
NPI:1629553300
Name:FULLER, LINDA DIANE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DIANE
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860075
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0075
Mailing Address - Country:US
Mailing Address - Phone:507-665-6299
Mailing Address - Fax:
Practice Address - Street 1:1900 SUNRISE DR STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-5385
Practice Address - Country:US
Practice Address - Phone:507-665-6299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA152724363L00000X, 363LF0000X
MN6109363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6109OtherLICENSE