Individual
MR. JEFFREY S FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
1406 W BELLA DRIVE, MARION, IN 46953-5229
(765) 662-7720
(765) 573-5660
Mailing address
330 N WABASH, STE G20, MARION, IN 46952-2600
(765) 660-7600
(765) 651-7313
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
71002856A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000600494
ANTHEM
IN
05
—
200929110
—
IN
Enumeration date
01/28/2009
Last updated
10/20/2020
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