Provider Demographics
NPI:1467204412
Name:FULLER, CARA NICOLE
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:NICOLE
Last Name:FULLER
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 1:712 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-4216
Mailing Address - Country:US
Mailing Address - Phone:602-386-0012
Mailing Address - Fax:
Practice Address - Street 1:212 E DUKE STREET
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator