Provider Demographics
NPI:1508620659
Name:FULLER, LINESHA MONAE
Entity Type:Individual
Prefix:
First Name:LINESHA
Middle Name:MONAE
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 1:445 EAST DUBLIN GRANVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085
Mailing Address - Country:US
Mailing Address - Phone:614-844-3800
Mailing Address - Fax:
Practice Address - Street 1:690 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ROSSFORD
Practice Address - State:OH
Practice Address - Zip Code:43460
Practice Address - Country:US
Practice Address - Phone:614-844-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X, 3747P1801X
OH171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant