Individual
MRS. MARY FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DNP
Contact information
Practice address
110 N BURR BLVD, KEWANEE, IL 61443-2214
(309) 852-0197
(309) 854-5575
Mailing address
110 N BURR BLVD, KEWANEE, IL 61443-2214
(309) 852-0197
(309) 854-5575
Taxonomy
Speciality
Code
Description
License number
State
2083P0901X
Public Health & General Preventive Medicine Physician
209021513
IL
363L00000X
Nurse Practitioner
Primary
209021513
IL
363LP2300X
Primary Care Nurse Practitioner
209021513
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
366006568001
—
IL
Enumeration date
07/29/2020
Last updated
08/04/2020
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