Provider Demographics
NPI:1417407867
Name:FULLMER, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:FULLMER
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 1:251 RUSTIC CIR
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-3041
Mailing Address - Country:US
Mailing Address - Phone:248-672-7984
Mailing Address - Fax:
Practice Address - Street 1:251 RUSTIC CIR
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-3041
Practice Address - Country:US
Practice Address - Phone:248-672-7984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other