Provider Demographics
NPI:1760550396
Name:FULLENKAMP, JENNIFER MENKE (ARNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MENKE
Last Name:FULLENKAMP
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 1:1201 W AGENCY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1645
Mailing Address - Country:US
Mailing Address - Phone:319-754-4242
Mailing Address - Fax:319-754-4079
Practice Address - Street 1:1201 W AGENCY RD
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1645
Practice Address - Country:US
Practice Address - Phone:319-754-4242
Practice Address - Fax:319-754-4079
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA065341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP71319Medicare UPIN
IAI7569Medicare PIN