Provider Demographics
NPI:1528413382
Name:FULLER, JODIE ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 ORIENT ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-1633
Mailing Address - Country:US
Mailing Address - Phone:585-205-3303
Mailing Address - Fax:
Practice Address - Street 1:712 ORIENT ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1633
Practice Address - Country:US
Practice Address - Phone:585-205-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168173-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse