Provider Demographics
NPI:1053346791
Name:FULLER, SHERRI (NP)
Entity type:Individual
Prefix:
First Name:SHERRI
Middle Name:
Last Name:FULLER
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 1:303 E NICOLLET BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4522
Mailing Address - Country:US
Mailing Address - Phone:952-460-4000
Mailing Address - Fax:952-460-4000
Practice Address - Street 1:303 E NICOLLET BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4522
Practice Address - Country:US
Practice Address - Phone:952-460-4000
Practice Address - Fax:952-460-4000
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1104617363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN126518100Medicaid
R96808Medicare UPIN