Provider Demographics
NPI:1386350742
Name:FULLER, NICOLE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 WASHINGTON ST APT 1222
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-4905
Mailing Address - Country:US
Mailing Address - Phone:717-448-0134
Mailing Address - Fax:
Practice Address - Street 1:2003 LOWER STATE RD # BLGD200
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2622
Practice Address - Country:US
Practice Address - Phone:215-345-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty