Provider Demographics
NPI:1447872692
Name:FULLER, MARY ELIZABETH (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:FULLER
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 GRAPEVINE HWY
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2805
Mailing Address - Country:US
Mailing Address - Phone:817-428-7300
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3844
Practice Address - Country:US
Practice Address - Phone:940-626-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145920363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner