Provider Demographics
NPI:1518370022
Name:FULLER, ROB (HAD)
Entity Type:Individual
Prefix:
First Name:ROB
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LINCOLN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-4900
Mailing Address - Country:US
Mailing Address - Phone:707-255-1692
Mailing Address - Fax:707-255-1039
Practice Address - Street 1:1100 LINCOLN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-4900
Practice Address - Country:US
Practice Address - Phone:707-255-1692
Practice Address - Fax:707-255-1039
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7682237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist