Provider Demographics
NPI:1790046654
Name:FULLER, AUNDRA LAMAR
Entity Type:Individual
Prefix:MR
First Name:AUNDRA
Middle Name:LAMAR
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10922 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-2703
Mailing Address - Country:US
Mailing Address - Phone:918-282-6850
Mailing Address - Fax:
Practice Address - Street 1:10922 E. 39TH ST.
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146
Practice Address - Country:US
Practice Address - Phone:918-282-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK99999999999999999999103K00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst