Provider Demographics
NPI:1902468556
Name:FULLER, NICKY
Entity Type:Individual
Prefix:
First Name:NICKY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 NW 45TH TER
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5744
Mailing Address - Country:US
Mailing Address - Phone:786-479-9977
Mailing Address - Fax:
Practice Address - Street 1:1 W SAMPLE RD STE 103
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3547
Practice Address - Country:US
Practice Address - Phone:954-942-6868
Practice Address - Fax:954-942-6854
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003023363LF0000X
FLAPRN11003023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily