Provider Demographics
NPI:1619448370
Name:FULLER, TASHA MARIE (DC)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E ELISHA ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1402
Mailing Address - Country:US
Mailing Address - Phone:315-664-2216
Mailing Address - Fax:
Practice Address - Street 1:47 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1444
Practice Address - Country:US
Practice Address - Phone:315-664-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013201111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor