Provider Demographics
NPI:1033223631
Name:FULLER, JILL MARIE (MSN, CNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MSN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 STATE ST STE 606
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1826
Mailing Address - Country:US
Mailing Address - Phone:814-454-3811
Mailing Address - Fax:814-454-3422
Practice Address - Street 1:1001 STATE ST STE 606
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1826
Practice Address - Country:US
Practice Address - Phone:814-454-3811
Practice Address - Fax:814-454-3422
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009500363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ22792Medicare UPIN