Provider Demographics
NPI:1174009617
Name:FULLERTON, TINAMARIE
Entity Type:Individual
Prefix:
First Name:TINAMARIE
Middle Name:
Last Name:FULLERTON
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 1:1392 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4013
Mailing Address - Country:US
Mailing Address - Phone:631-374-1190
Mailing Address - Fax:
Practice Address - Street 1:1392 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4013
Practice Address - Country:US
Practice Address - Phone:631-374-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula