Provider Demographics
NPI:1124347786
Name:FULLER, DIANNE LEE (FNP-C)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:LEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:LEE
Other - Last Name:FULLER CLYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:10 S 2000 E
Mailing Address - Street 2:UNIVERSITY OF UTAH COLLEGE OF NURSING
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5880
Mailing Address - Country:US
Mailing Address - Phone:801-582-5573
Mailing Address - Fax:
Practice Address - Street 1:3690 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4423
Practice Address - Country:US
Practice Address - Phone:801-910-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT308008-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily