Provider Demographics
NPI:1700869773
Name:FULLER, JAYNEE LEE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:JAYNEE
Middle Name:LEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33920 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 214
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-2654
Mailing Address - Country:US
Mailing Address - Phone:727-779-9793
Mailing Address - Fax:727-773-0674
Practice Address - Street 1:35 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3139
Practice Address - Country:US
Practice Address - Phone:706-747-1036
Practice Address - Fax:706-747-1046
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9228873363L00000X
GARN227177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010894Medicaid
S43491Medicare UPIN
NHMP0786Medicare ID - Type Unspecified