Provider Demographics
NPI:1366525545
Name:FULLER-HASKELL, ELISABETH ANN (NP)
Entity type:Individual
Prefix:MRS
First Name:ELISABETH
Middle Name:ANN
Last Name:FULLER-HASKELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 PLEASANT LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:HARWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02645-2535
Mailing Address - Country:US
Mailing Address - Phone:508-432-5233
Mailing Address - Fax:508-430-0511
Practice Address - Street 1:253 PLEASANT LAKE AVE
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-2535
Practice Address - Country:US
Practice Address - Phone:508-432-5233
Practice Address - Fax:508-430-0511
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160499363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NP0055OtherBCBS
MANP 0055OtherBCBS
UX3415OtherPTAN
MA0353761Medicaid
NP0055OtherBCBS
UX3415OtherPTAN