Provider Demographics
NPI:1952435059
Name:FULLER, ELISE J (PHD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT. 1193
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:90291-1193
Mailing Address - Country:US
Mailing Address - Phone:303-486-5504
Mailing Address - Fax:303-486-5501
Practice Address - Street 1:3207 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5100
Practice Address - Country:US
Practice Address - Phone:719-776-3600
Practice Address - Fax:719-776-3610
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist