Provider Demographics
NPI:1275859720
Name:FULLER, DALE DEBRA (NLMT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:DEBRA
Last Name:FULLER
Suffix:
Gender:F
Credentials:NLMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2161 SARAH CT
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-7933
Mailing Address - Country:US
Mailing Address - Phone:570-406-1975
Mailing Address - Fax:570-406-1975
Practice Address - Street 1:2161 SARAH CT
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301
Practice Address - Country:US
Practice Address - Phone:570-406-1975
Practice Address - Fax:570-406-1975
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG003284172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist