Provider Demographics
NPI:1518763374
Name:FULLER, NICHOLAS GREY (RN)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GREY
Last Name:FULLER
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:GREY
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:110 W MARSHALL ST APT 38
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-3984
Mailing Address - Country:US
Mailing Address - Phone:276-285-4610
Mailing Address - Fax:
Practice Address - Street 1:1300 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5028
Practice Address - Country:US
Practice Address - Phone:804-828-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001326753163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult