Provider Demographics
NPI:1073636494
Name:FULLER, ANTHONY DEMETRIUS (LPN)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:DEMETRIUS
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 THE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1433
Mailing Address - Country:US
Mailing Address - Phone:631-608-8741
Mailing Address - Fax:
Practice Address - Street 1:44 THE BLVD
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1433
Practice Address - Country:US
Practice Address - Phone:631-608-8741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228275164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse