Provider Demographics
NPI:1093447385
Name:FULLER, IMANI S
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:S
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 1:1480 PASEO VERDE PKWY APT 3211
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-6510
Mailing Address - Country:US
Mailing Address - Phone:323-793-3875
Mailing Address - Fax:
Practice Address - Street 1:1480 PASEO VERDE PKWY APT 3211
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-6510
Practice Address - Country:US
Practice Address - Phone:323-793-3875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician