Provider Demographics
NPI:1508545492
Name:FULLER, DOROTHY ILERT (MBA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ILERT
Last Name:FULLER
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9439 N SAYBROOK DR APT 228
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0636
Mailing Address - Country:US
Mailing Address - Phone:615-525-3523
Mailing Address - Fax:
Practice Address - Street 1:9439 N SAYBROOK DR APT 228
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0636
Practice Address - Country:US
Practice Address - Phone:615-525-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier