Provider Demographics
NPI:1629268800
Name:FULLER, CONNIE M (PT)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:50475 GRATIOT
Mailing Address - Street 2:SUITE B PHYSICAL THERAPY PROFESSIONALS PC
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-3128
Mailing Address - Country:US
Mailing Address - Phone:586-598-0050
Mailing Address - Fax:586-598-1804
Practice Address - Street 1:50475 GRATIOT
Practice Address - Street 2:SUITE B PHYSICAL THERAPY PROFESSIONALS PC
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3128
Practice Address - Country:US
Practice Address - Phone:586-598-0050
Practice Address - Fax:586-598-1804
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501005085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist