Provider Demographics
NPI:1578343281
Name:FULLER, MI'KIA RUTH ELIZABETH I (STNA)
Entity Type:Individual
Prefix:MS
First Name:MI'KIA
Middle Name:RUTH ELIZABETH
Last Name:FULLER
Suffix:I
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17010 ELSIENNA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-1906
Mailing Address - Country:US
Mailing Address - Phone:216-507-4737
Mailing Address - Fax:
Practice Address - Street 1:17010 ELSIENNA AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-1906
Practice Address - Country:US
Practice Address - Phone:216-507-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide