Provider Demographics
NPI:1871731935
Name:FULLER, JEFFREY S (NP)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:S
Last Name:FULLER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:330 N WABASH
Mailing Address - Street 2:STE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1406 W BELLA DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5229
Practice Address - Country:US
Practice Address - Phone:765-662-7720
Practice Address - Fax:765-573-5660
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71002856A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000600494OtherANTHEM
IN200929110Medicaid
IN200929110Medicaid