Provider Demographics
NPI:1538520002
Name:FULLER, LATONYA
Entity Type:Individual
Prefix:
First Name:LATONYA
Middle Name:
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 1:12829 LEVERNE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2732
Mailing Address - Country:US
Mailing Address - Phone:734-744-9667
Mailing Address - Fax:734-744-9668
Practice Address - Street 1:27578 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2203
Practice Address - Country:US
Practice Address - Phone:734-744-9667
Practice Address - Fax:734-744-9668
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)