Basic Information
| Provider Information | |||||||||
| NPI: | 1346753464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | AMELIA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2797 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681032797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544230 | ||||||||
| FaxNumber: | 4023546171 | ||||||||
| Practice Location | |||||||||
| Address1: | 8303 DODGE ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544000 | ||||||||
| FaxNumber: | 4023548469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2017 | ||||||||
| LastUpdateDate: | 03/05/2018 | ||||||||
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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 | 363L00000X | 112367 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 47037660432 | 05 | NE | MEDICAID | 1346753464 | 05 | IA | MEDICAID |