Provider Demographics
NPI:1275176901
Name:FULLER, PATRICIA LYNN
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:LYNN
Other - Last Name:MCGUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3554 WESTWOOD RD NE
Mailing Address - Street 2:
Mailing Address - City:MANCELONA
Mailing Address - State:MI
Mailing Address - Zip Code:49659-9539
Mailing Address - Country:US
Mailing Address - Phone:231-676-9859
Mailing Address - Fax:231-916-2347
Practice Address - Street 1:3554 WESTWOOD RD NE
Practice Address - Street 2:
Practice Address - City:MANCELONA
Practice Address - State:MI
Practice Address - Zip Code:49659-9539
Practice Address - Country:US
Practice Address - Phone:231-676-9859
Practice Address - Fax:231-916-2347
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI802059811251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802059811OtherAUTO CLAIMS