Basic Information
| Provider Information | |||||||||
| NPI: | 1215512074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 CLAYTON GLENN RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275747749 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 CRUTCHFIELD ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195607305 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2021 | ||||||||
| LastUpdateDate: | 03/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 5014181 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.