Provider Demographics
NPI:1407307721
Name:FULARA, ELISE (MA, IBCLC, RLC)
Entity Type:Individual
Prefix:MS
First Name:ELISE
Middle Name:
Last Name:FULARA
Suffix:
Gender:F
Credentials:MA, IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 S FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4217
Mailing Address - Country:US
Mailing Address - Phone:630-779-3830
Mailing Address - Fax:
Practice Address - Street 1:708 S FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-4217
Practice Address - Country:US
Practice Address - Phone:630-779-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-100786174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN