Provider Demographics
NPI:1417182692
Name:FULLER, ADRIANNE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ADRIANNE
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 702
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:IL
Mailing Address - Zip Code:61732-0702
Mailing Address - Country:US
Mailing Address - Phone:773-937-7878
Mailing Address - Fax:
Practice Address - Street 1:2810 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4201
Practice Address - Country:US
Practice Address - Phone:773-937-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.009183225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist