Provider Demographics
NPI:1013587468
Name:FULLER, BREANNA BIANCA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:BIANCA
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 1:1486 HUNTINGTON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5971
Mailing Address - Country:US
Mailing Address - Phone:650-276-4101
Mailing Address - Fax:
Practice Address - Street 1:1486 HUNTINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5971
Practice Address - Country:US
Practice Address - Phone:650-276-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program