Provider Demographics
NPI:1598194656
Name:FULLER, LOIS
Entity Type:Individual
Prefix:MRS
First Name:LOIS
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 1:14857 N TYLER ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1078
Mailing Address - Country:US
Mailing Address - Phone:918-931-9131
Mailing Address - Fax:
Practice Address - Street 1:14857 N TYLER ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-1078
Practice Address - Country:US
Practice Address - Phone:918-931-9131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health