Provider Demographics
NPI:1366866204
Name:FULLER, ANGELIA (ARNP)
Entity type:Individual
Prefix:
First Name:ANGELIA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 TREE BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5719
Mailing Address - Country:US
Mailing Address - Phone:904-342-0672
Mailing Address - Fax:
Practice Address - Street 1:1750 TREE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5719
Practice Address - Country:US
Practice Address - Phone:904-342-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9170137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102979000Medicaid