Provider Demographics
NPI:1588069223
Name:FULLER, JANE ELIZABETH MERIE (RN)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:ELIZABETH MERIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:ELIZABETH MERIE
Other - Last Name:OCHELTREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDA
Mailing Address - Street 1:1215 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2237
Mailing Address - Country:US
Mailing Address - Phone:714-516-9045
Mailing Address - Fax:714-516-9860
Practice Address - Street 1:1215 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2237
Practice Address - Country:US
Practice Address - Phone:714-516-9045
Practice Address - Fax:714-516-9860
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA792747163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330150193OtherMEDICAL