Provider Demographics
NPI:1619577103
Name:FULLER, GENA (ATC/L)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 VOIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1537
Mailing Address - Country:US
Mailing Address - Phone:203-814-8108
Mailing Address - Fax:
Practice Address - Street 1:4675 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1813
Practice Address - Country:US
Practice Address - Phone:203-373-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1026OtherSTATE LICENSE