Provider Demographics
NPI:1790176600
Name:FULLER, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
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 1:4287 OTTERBEIN RD
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:OHIO
Mailing Address - Zip Code:43150
Mailing Address - Country:UM
Mailing Address - Phone:740-743-1168
Mailing Address - Fax:740-743-1168
Practice Address - Street 1:4287 OTTERBEIN RD
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:OH
Practice Address - Zip Code:43150-9607
Practice Address - Country:US
Practice Address - Phone:740-743-1168
Practice Address - Fax:740-743-1168
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401115530710251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105578Medicaid