Provider Demographics
NPI:1154574416
Name:FULLER, JILL ELIZABETH (FNP-BC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ELIZABETH
Last Name:FULLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2633
Mailing Address - Country:US
Mailing Address - Phone:860-429-9321
Mailing Address - Fax:860-429-4775
Practice Address - Street 1:1022 STORRS RD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2633
Practice Address - Country:US
Practice Address - Phone:860-429-9321
Practice Address - Fax:860-429-4775
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily