1639447691 NPI number — MELINDA S FULLER CRNP

Table of content: MELINDA S FULLER CRNP (NPI 1639447691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639447691 NPI number — MELINDA S FULLER CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
MELINDA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639447691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17402-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-851-2465
Provider Business Mailing Address Fax Number:
717-741-3043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 FREEDOM WAY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17402-8200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-851-2465
Provider Business Practice Location Address Fax Number:
717-741-3043
Provider Enumeration Date:
12/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  SP011669 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1605971 . This is a "GATEWAY MEDICARE ASSURED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2682788 . This is a "HIGHMARK BLUE SHIELD - FREEDOM BLUE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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