Provider Demographics
NPI:1659970275
Name:FULLER, NIMOL
Entity Type:Individual
Prefix:
First Name:NIMOL
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 E SAUNDERS ST STE B370
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5449
Mailing Address - Country:US
Mailing Address - Phone:956-726-4743
Mailing Address - Fax:
Practice Address - Street 1:1710 E SAUNDERS ST STE B370
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5449
Practice Address - Country:US
Practice Address - Phone:956-726-4743
Practice Address - Fax:956-794-8822
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1017822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily