Provider Demographics
NPI:1306462908
Name:FULLER, JULIE A (RN, MSN, CNM)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN, MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 N M 52 STE 2
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1519
Mailing Address - Country:US
Mailing Address - Phone:989-729-4292
Mailing Address - Fax:989-725-9012
Practice Address - Street 1:1457 N M 52 STE 2
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1519
Practice Address - Country:US
Practice Address - Phone:989-729-4292
Practice Address - Fax:989-725-9012
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259711367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306462908Medicaid