Provider Demographics
NPI:1003449422
Name:FULLER, MARGARET ANN
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-704-5612
Mailing Address - Fax:858-404-1803
Practice Address - Street 1:15004 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3491
Practice Address - Country:US
Practice Address - Phone:858-605-7189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2048225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation