Provider Demographics
NPI:1356870588
Name:FULLER, EMILY A (CRNA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANNE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-6015
Practice Address - Country:US
Practice Address - Phone:570-271-6621
Practice Address - Fax:570-271-6762
Is Sole Proprietor?:No
Enumeration Date:2017-06-10
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN229306163W00000X, 367500000X
PARN712729367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse