Provider Demographics
NPI:1639804529
Name:FULLER, MELISSA DAWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
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 1:9489 LEE ROAD 379
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36854-6686
Mailing Address - Country:US
Mailing Address - Phone:234-524-1969
Mailing Address - Fax:
Practice Address - Street 1:9489 LEE ROAD 379
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-6686
Practice Address - Country:US
Practice Address - Phone:234-524-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-112786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily