Provider Demographics
NPI:1093352684
Name:FULLER, YVONNE JANICE
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:JANICE
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 MELROSE LN APT 4
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-5149
Mailing Address - Country:US
Mailing Address - Phone:405-706-6764
Mailing Address - Fax:
Practice Address - Street 1:2808 NW 31ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7407
Practice Address - Country:US
Practice Address - Phone:405-706-6764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist