Provider Demographics
NPI:1043771611
Name:FULLER, NICHOLAS WINFREY (LPTA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:WINFREY
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-7616
Mailing Address - Country:US
Mailing Address - Phone:540-818-2257
Mailing Address - Fax:
Practice Address - Street 1:1229 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-3131
Practice Address - Country:US
Practice Address - Phone:540-586-7658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605097225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant