Provider Demographics
NPI:1760090765
Name:FULLER, EDWANA DENISE (RN)
Entity Type:Individual
Prefix:
First Name:EDWANA
Middle Name:DENISE
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 S INDIANA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4712
Mailing Address - Country:US
Mailing Address - Phone:773-299-2777
Mailing Address - Fax:
Practice Address - Street 1:5319 S INDIANA AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4712
Practice Address - Country:US
Practice Address - Phone:773-299-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28258565A163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28258565AOtherLICENSE NUMBER