Provider Demographics
NPI:1851364590
Name:FULLER, BEVERLY JUNE (CRNA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JUNE
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 264TH ST
Mailing Address - Street 2:
Mailing Address - City:O BRIEN
Mailing Address - State:FL
Mailing Address - Zip Code:32071
Mailing Address - Country:US
Mailing Address - Phone:386-935-4262
Mailing Address - Fax:
Practice Address - Street 1:1160 SE 18TH PL
Practice Address - Street 2:OCALA ENDOSCOPY CENTER
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:32071
Practice Address - Country:US
Practice Address - Phone:352-732-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 999812367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034147900Medicaid
G0672Medicare ID - Type Unspecified