Provider Demographics
NPI:1639447691
Name:FULLER, MELINDA S (CRNP)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:S
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-2465
Mailing Address - Fax:717-741-3043
Practice Address - Street 1:2350 FREEDOM WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8200
Practice Address - Country:US
Practice Address - Phone:717-851-2465
Practice Address - Fax:717-741-3043
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011669363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1605971OtherGATEWAY MEDICARE ASSURED
PA2682788OtherHIGHMARK BLUE SHIELD - FREEDOM BLUE
PA2682788OtherHIGHMARK BLUE SHIELD - FREEDOM BLUE
PA1605971OtherGATEWAY MEDICARE ASSURED