Provider Demographics
NPI:1215512611
Name:FULLER, BONNIE NALL (APRN)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:NALL
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:YALAHA
Mailing Address - State:FL
Mailing Address - Zip Code:34797-3032
Mailing Address - Country:US
Mailing Address - Phone:850-960-6038
Mailing Address - Fax:
Practice Address - Street 1:16 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:YALAHA
Practice Address - State:FL
Practice Address - Zip Code:34797-3032
Practice Address - Country:US
Practice Address - Phone:850-960-6038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11012161OtherFLORIDA DEPARTMENT OF HEALTH BOARD OF NURSING