Provider Demographics
NPI:1245745835
Name:FULLER, MARLENE
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
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 1:12097 OLD HAMMOND HWY STE I2
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8679
Mailing Address - Country:US
Mailing Address - Phone:225-831-9249
Mailing Address - Fax:225-831-9248
Practice Address - Street 1:12097 OLD HAMMOND HWY STE I2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8679
Practice Address - Country:US
Practice Address - Phone:225-831-9249
Practice Address - Fax:225-831-9248
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator