Provider Demographics
NPI:1497258891
Name:FULLER, TERESA AUSTIN
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:AUSTIN
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 1:4755 S COUNTY ROAD O
Mailing Address - Street 2:
Mailing Address - City:MAPLE
Mailing Address - State:WI
Mailing Address - Zip Code:54854-9159
Mailing Address - Country:US
Mailing Address - Phone:218-269-7961
Mailing Address - Fax:715-363-2615
Practice Address - Street 1:4755 S COUNTY ROAD O
Practice Address - Street 2:
Practice Address - City:MAPLE
Practice Address - State:WI
Practice Address - Zip Code:54854-9159
Practice Address - Country:US
Practice Address - Phone:218-269-7961
Practice Address - Fax:715-363-2615
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)