Provider Demographics
NPI:1558662494
Name:FULLER, REBECCA CHRISTINE (RD)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:CHRISTINE
Last Name:FULLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:CHRISTINE
Other - Last Name:EASTEP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3413 FLETTON WAY
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-4022
Mailing Address - Country:US
Mailing Address - Phone:937-397-4917
Mailing Address - Fax:
Practice Address - Street 1:3000 ST MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1498
Practice Address - Country:US
Practice Address - Phone:803-395-4478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC691133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7399Medicare PIN
SC7389Medicare PIN