Provider Demographics
NPI:1063645299
Name:FULLMER, MICHELL A (RD)
Entity Type:Individual
Prefix:MS
First Name:MICHELL
Middle Name:A
Last Name:FULLMER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:MICHELL
Other - Middle Name:ANN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1600 ROCKLAND RD
Mailing Address - Street 2:AIDHC NUTRITION SERVICES
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3607
Mailing Address - Country:US
Mailing Address - Phone:302-651-4839
Mailing Address - Fax:302-651-4737
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:AIDHC NUTRITION SERVICES
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4839
Practice Address - Fax:302-651-4737
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN0000227133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric