Provider Demographics
NPI:1508227257
Name:FULLER, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
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 1:4821 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-5648
Mailing Address - Country:US
Mailing Address - Phone:713-653-3072
Mailing Address - Fax:
Practice Address - Street 1:4821 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-5648
Practice Address - Country:US
Practice Address - Phone:713-653-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246ZE0600X246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic