Active NPI
Edwana Denise Fuller, RN
- Medical-Surgical Registered Nurse
- Chicago, IL
National Provider Identifier
1760090765
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical-Surgical Registered Nurse
- License
- 28258565A
- Practice address
- 5319 S Indiana Ave Apt 1
Chicago, IL 60615-4712 - Phone
- (773) 299-2777
- NPI assigned
- Jul 16, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical-Surgical Registered Nurse | 163WM0705X | 28258565A | IN | Primary |
Addresses
Primary practice location
5319 S Indiana Ave Apt 1
Chicago, IL 60615-4712
Mailing address
5319 S Indiana Ave Apt 1
Chicago, IL 60615-4712
Phone (773) 299-2777
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 28258565A | Other | IN | LICENSE NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 28258565A | IN | MD | Medical-Surgical Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1594857600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1594857600000",
"number": "1760090765",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5319 S INDIANA AVE APT 1",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606154712",
"telephone_number": "773-299-2777"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5319 S INDIANA AVE APT 1",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606154712",
"telephone_number": "773-299-2777"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FULLER",
"first_name": "EDWANA",
"middle_name": "DENISE",
"credential": "RN",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-07-16",
"last_updated": "2020-07-16",
"certification_date": "2020-07-16",
"status": "A"
},
"taxonomies": [
{
"code": "163WM0705X",
"taxonomy_group": "",
"desc": "Registered Nurse, Medical-Surgical",
"state": "IN",
"license": "28258565A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSE NUMBER",
"identifier": "28258565A",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.