Provider Demographics
NPI:1629212857
Name:FULLER, MARCIA LYNN (MS)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-2089
Mailing Address - Country:US
Mailing Address - Phone:479-750-0125
Mailing Address - Fax:479-750-0323
Practice Address - Street 1:519 LATHAM DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8360
Practice Address - Country:US
Practice Address - Phone:479-750-0125
Practice Address - Fax:479-750-0323
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR97-24 E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist