Individual
EDWANA DENISE FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RN
Contact information
Practice address
5319 S INDIANA AVE APT 1, CHICAGO, IL 60615-4712
(773) 299-2777
Mailing address
5319 S INDIANA AVE APT 1, CHICAGO, IL 60615-4712
(773) 299-2777
Taxonomy
Speciality
Code
Description
License number
State
163WM0705X
Medical-Surgical Registered Nurse
Primary
28258565A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
28258565A
LICENSE NUMBER
IN
Enumeration date
07/16/2020
Last updated
07/16/2020
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