Provider Demographics
NPI:1073375192
Name:FULLER, AMANDA (COMMUNITY HEALTH WOR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:COMMUNITY HEALTH WOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 M 62
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031
Mailing Address - Country:US
Mailing Address - Phone:269-445-3874
Mailing Address - Fax:269-445-1930
Practice Address - Street 1:1951 OAK ST.
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120
Practice Address - Country:US
Practice Address - Phone:269-262-4749
Practice Address - Fax:269-262-4739
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker