Provider Demographics
NPI:1952421059
Name:FULLER, KOLLEEN MARIAN (RNNP)
Entity Type:Individual
Prefix:MS
First Name:KOLLEEN
Middle Name:MARIAN
Last Name:FULLER
Suffix:
Gender:F
Credentials:RNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 FENNELL ST
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152-1119
Mailing Address - Country:US
Mailing Address - Phone:315-685-0023
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7111
Practice Address - Fax:315-470-2642
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300761-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care