Basic Information
| Provider Information | |||||||||
| NPI: | 1629444666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | JOSELYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONDER | ||||||||
| OtherFirstName: | JOSELYN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 96398 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731436398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009623303 | ||||||||
| FaxNumber: | 4056091466 | ||||||||
| Practice Location | |||||||||
| Address1: | 3580 W 9000 SOUTH | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840888899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015618888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2015 | ||||||||
| LastUpdateDate: | 04/12/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7327150-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 7327150 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.