Provider Demographics
NPI:1639344344
Name:FULLER, STANLEY B SR (LPN)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:B
Last Name:FULLER
Suffix:SR
Gender:M
Credentials:LPN
Other - Prefix:MR
Other - First Name:STANLEY
Other - Middle Name:B
Other - Last Name:FULLER
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:117 N WAYNE ST
Mailing Address - Street 2:117 N WAYNE ST
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2431
Mailing Address - Country:US
Mailing Address - Phone:419-307-2984
Mailing Address - Fax:
Practice Address - Street 1:117 N WAYNE ST
Practice Address - Street 2:117 N WAYNE ST
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-2431
Practice Address - Country:US
Practice Address - Phone:419-307-2984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.102037164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse