Basic Information
| Provider Information | |||||||||
| NPI: | 1053346791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | SHERRI | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 E NICOLLET BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524604000 | ||||||||
| FaxNumber: | 9524604000 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 E NICOLLET BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524604000 | ||||||||
| FaxNumber: | 9524604000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R1104617 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 126518100 | 05 | MN | MEDICAID |