Provider Demographics
NPI:1740406974
Name:FULLER-FRANCIS, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:FULLER-FRANCIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-3108
Mailing Address - Country:US
Mailing Address - Phone:212-876-2300
Mailing Address - Fax:212-722-7618
Practice Address - Street 1:2369 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3108
Practice Address - Country:US
Practice Address - Phone:212-876-2300
Practice Address - Fax:212-722-7618
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287072-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02841069Medicaid