Provider Demographics
NPI:1780106831
Name:FULLER, SABRINA MISTY
Entity type:Individual
Prefix:
First Name:SABRINA
Middle Name:MISTY
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 LAKE ELLENOR DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-4616
Mailing Address - Country:US
Mailing Address - Phone:407-723-5029
Mailing Address - Fax:407-858-5523
Practice Address - Street 1:6101 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4616
Practice Address - Country:US
Practice Address - Phone:407-858-1487
Practice Address - Fax:407-845-6136
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9228514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022688100Medicaid