Provider Demographics
NPI:1760847461
Name:FULLER, LISA (RN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
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 1:38 ALBANY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8122
Mailing Address - Country:US
Mailing Address - Phone:573-445-2180
Mailing Address - Fax:
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014006880163WM0705X, 163W00000X, 163WN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience