Provider Demographics
NPI:1972873206
Name:FULLER, CATHY M (ANP)
Entity Type:Individual
Prefix:MS
First Name:CATHY
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N HENNESS RD LOT 1269
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5559
Mailing Address - Country:US
Mailing Address - Phone:520-876-7269
Mailing Address - Fax:
Practice Address - Street 1:1110 N HENNESS RD LOT 1269
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5559
Practice Address - Country:US
Practice Address - Phone:520-876-7269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3750363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health