Provider Demographics
NPI:1609080985
Name:FULLER, BEATRICE LYNNE
Entity Type:Individual
Prefix:
First Name:BEATRICE LYNNE
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 1:1136 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1909
Mailing Address - Country:US
Mailing Address - Phone:267-886-9367
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:610-834-7525
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATLPN003944164W00000X
FLPN5157986164W00000X
TX205047164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered164W00000XNursing Service ProvidersLicensed Practical Nurse
Not Answered164X00000XNursing Service ProvidersLicensed Vocational Nurse