Provider Demographics
NPI:1326503707
Name:FULLER, MARY ALISE
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ALISE
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 1:2396 ELVANS RD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3504
Mailing Address - Country:US
Mailing Address - Phone:202-790-2335
Mailing Address - Fax:
Practice Address - Street 1:3030 30TH ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-1674
Practice Address - Country:US
Practice Address - Phone:202-241-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant