Provider Demographics
NPI:1427472083
Name:FULLER, JO L (APRN-CNP)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0216
Mailing Address - Country:US
Mailing Address - Phone:580-221-7500
Mailing Address - Fax:580-490-9406
Practice Address - Street 1:2401 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1280
Practice Address - Country:US
Practice Address - Phone:580-226-0543
Practice Address - Fax:580-226-2284
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK75953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200526780AMedicaid