Provider Demographics
NPI:1881338523
Name:FULLER, CORTNEY D (BSN, RN, ICP, CPN)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:D
Last Name:FULLER
Suffix:
Gender:F
Credentials:BSN, RN, ICP, CPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 WATERLANE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9105
Mailing Address - Country:US
Mailing Address - Phone:574-261-0391
Mailing Address - Fax:
Practice Address - Street 1:200 S 14TH ST STE 140
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-3361
Practice Address - Country:US
Practice Address - Phone:817-369-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX854917163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse