Provider Demographics
NPI:1326155128
Name:FULLER, MIMI O (CNA)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:O
Last Name:FULLER
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 E MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1281
Mailing Address - Country:US
Mailing Address - Phone:864-542-1308
Mailing Address - Fax:
Practice Address - Street 1:735 E MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1281
Practice Address - Country:US
Practice Address - Phone:864-542-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSCAPN987367500000X
SCAANA22356367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0665Medicaid
SCP94248Medicare UPIN