Provider Demographics
NPI:1750396222
Name:MAKOVEC-FULLER, ANNA (CFNP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:MAKOVEC-FULLER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SHOUP AVE W
Mailing Address - Street 2:SUITE E
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-2885
Mailing Address - Fax:208-734-3352
Practice Address - Street 1:496 SHOUP AVE W
Practice Address - Street 2:SUITE E
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-2885
Practice Address - Fax:208-734-3352
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP233A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDNPGT7OtherBLUE CROSS
ID000010029066OtherREGENCE BLUE SHIELD
ID13418371Medicare PIN
IDNPGT7OtherBLUE CROSS