Provider Demographics
NPI:1851668271
Name:FULLER, JACLYN NICOLE (CRNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 BROOKWOOD BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209
Mailing Address - Country:US
Mailing Address - Phone:205-870-0256
Mailing Address - Fax:205-870-7107
Practice Address - Street 1:1010 1ST STREET NORTH
Practice Address - Street 2:SUITE 112
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007
Practice Address - Country:US
Practice Address - Phone:205-663-1023
Practice Address - Fax:205-870-7107
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-108712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily