Provider Demographics
NPI:1417462896
Name:FULLER, CAROL KAY (PCA)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:KAY
Last Name:FULLER
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:KAY
Other - Last Name:SOWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:925 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530
Mailing Address - Country:US
Mailing Address - Phone:304-356-4562
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:925 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530
Practice Address - Country:US
Practice Address - Phone:304-453-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0033631000OtherPROVIDER ID