Provider Demographics
NPI:1962535674
Name:FULLER, ELIZABETH J (MSN, RN, CNS)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:MSN, RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 N CAPITOL AVE
Practice Address - Street 2:SUITE 436
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1261
Practice Address - Country:US
Practice Address - Phone:317-962-6603
Practice Address - Fax:317-962-2049
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28090249A364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28090249AOtherSTATE LICENSE
IN266130GMedicare PIN
IN0521920001Medicare NSC