Provider Demographics
NPI:1861474207
Name:FULLER, DEBORAH JOAN (CNP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JOAN
Last Name:FULLER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 CENTRO FAMILIAR BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4592
Mailing Address - Country:US
Mailing Address - Phone:505-281-3406
Mailing Address - Fax:505-286-3329
Practice Address - Street 1:7 MUNICIPAL WAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-281-3406
Practice Address - Fax:505-286-3329
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR42788363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner