Provider Demographics
NPI:1508404187
Name:FULLERTON, LESLI DEANA (RN)
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:DEANA
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LESLI
Other - Middle Name:DEANA
Other - Last Name:FULLERTON-PACIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1801 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2923
Mailing Address - Country:US
Mailing Address - Phone:415-681-3211
Mailing Address - Fax:
Practice Address - Street 1:1801 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-2923
Practice Address - Country:US
Practice Address - Phone:415-681-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA532239163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse