Provider Demographics
NPI:1790392041
Name:FULLER, MICHELLE RENEE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
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 1:1082 AMHERST BLVD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-8576
Mailing Address - Country:US
Mailing Address - Phone:614-209-5344
Mailing Address - Fax:
Practice Address - Street 1:1082 AMHERST BLVD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-8576
Practice Address - Country:US
Practice Address - Phone:614-209-5344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker