Provider Demographics
NPI:1093023806
Name:FULLER, MONIKA VIOLET (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MONIKA
Middle Name:VIOLET
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MONIKA
Other - Middle Name:
Other - Last Name:PIASCIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:836 FOXON RD
Mailing Address - Street 2:MEDICAL WEIGHT LOSS CENTER
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513
Mailing Address - Country:US
Mailing Address - Phone:203-468-9200
Mailing Address - Fax:203-468-9661
Practice Address - Street 1:836 FOXON RD
Practice Address - Street 2:MEDICAL WEIGHT LOSS CENTER
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-468-9200
Practice Address - Fax:203-468-9661
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002415363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant