Provider Demographics
NPI:1376724211
Name:FULLER, CARLA JUDITH (LPN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:JUDITH
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HUGHES ST E
Mailing Address - Street 2:PO BOX 316
Mailing Address - City:BELFAST
Mailing Address - State:NY
Mailing Address - Zip Code:14711-8725
Mailing Address - Country:US
Mailing Address - Phone:585-201-6166
Mailing Address - Fax:
Practice Address - Street 1:88 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-2074
Practice Address - Country:US
Practice Address - Phone:585-201-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217696-13140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02713931Medicaid