Provider Demographics
NPI:1689660466
Name:FULLER, MICHELLE L (NPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 WALNUT HILL LN
Mailing Address - Street 2:STE 220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4482
Mailing Address - Country:US
Mailing Address - Phone:214-750-3646
Mailing Address - Fax:214-368-1610
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:STE 220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-750-3646
Practice Address - Fax:214-368-1610
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX554440363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS60222Medicare UPIN
TX81N725Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER