Provider Demographics
NPI:1003393653
Name:FULLMER, TERI (ABO)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:FULLMER
Suffix:
Gender:F
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W EMERALD ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5003
Mailing Address - Country:US
Mailing Address - Phone:208-322-1642
Mailing Address - Fax:
Practice Address - Street 1:7447 W EMERALD ST STE 105
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5003
Practice Address - Country:US
Practice Address - Phone:208-322-1642
Practice Address - Fax:208-378-4179
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
065186OtherABO