Provider Demographics
NPI:1174272199
Name:FULLER, ANASTAZIA M
Entity Type:Individual
Prefix:
First Name:ANASTAZIA
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANASTAZIA
Other - Middle Name:M
Other - Last Name:ALVAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2800 LEXINGTON PL NE APT 24
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1331
Mailing Address - Country:US
Mailing Address - Phone:505-918-5510
Mailing Address - Fax:
Practice Address - Street 1:2800 LEXINGTON PL NE APT 24
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1331
Practice Address - Country:US
Practice Address - Phone:505-918-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician