Provider Demographics
NPI:1720767866
Name:FULLERTON, TODD D (DNP, RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:D
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:DNP, RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 MAPLE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2384
Mailing Address - Country:US
Mailing Address - Phone:816-876-4087
Mailing Address - Fax:
Practice Address - Street 1:1030 MAPLE WOODS DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2384
Practice Address - Country:US
Practice Address - Phone:816-876-4087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005242363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health