Provider Demographics
NPI:1619431129
Name:FULLER, DEBORAH E
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:E
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 1:118 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:MORVEN
Mailing Address - State:GA
Mailing Address - Zip Code:31638-2339
Mailing Address - Country:US
Mailing Address - Phone:404-839-2109
Mailing Address - Fax:
Practice Address - Street 1:1201 WILOAKS DR APT B
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-7406
Practice Address - Country:US
Practice Address - Phone:404-839-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker