Provider Demographics
NPI:1093969362
Name:FULLER, SHANNON NICHOLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICHOLE
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 1:3711 LONG BEACH BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3315
Mailing Address - Country:US
Mailing Address - Phone:562-485-3062
Mailing Address - Fax:562-216-2337
Practice Address - Street 1:3711 LONG BEACH BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3315
Practice Address - Country:US
Practice Address - Phone:562-485-3062
Practice Address - Fax:562-216-2337
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical