Provider Demographics
NPI:1114092178
Name:FULLER, LISA LYNN (MPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 QUEENS COURT
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501
Mailing Address - Country:US
Mailing Address - Phone:919-639-3791
Mailing Address - Fax:
Practice Address - Street 1:396 ELEMENTARY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-6267
Practice Address - Country:US
Practice Address - Phone:910-678-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist