Provider Demographics
NPI:1871371146
Name:FULLER, MELISSA J (APRN, AGCNS-BC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4079 LONGHORN DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-9634
Mailing Address - Country:US
Mailing Address - Phone:303-524-4507
Mailing Address - Fax:
Practice Address - Street 1:4747 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1131
Practice Address - Country:US
Practice Address - Phone:303-415-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0186597163WC1600X
COAPN.10000013-CNS364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development