Provider Demographics
NPI:1750658845
Name:FULLER, DENISE MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:MICHELLE
Last Name:FULLER
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 1:1510 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-4333
Mailing Address - Country:US
Mailing Address - Phone:580-255-3926
Mailing Address - Fax:
Practice Address - Street 1:1510 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4333
Practice Address - Country:US
Practice Address - Phone:580-255-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V369681004376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37V369681004OtherDEPARTMENT OF HEALTH