Provider Demographics
NPI:1801029814
Name:FULLER, SVETLANA GENNADIEVNA (RN)
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:GENNADIEVNA
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3507
Mailing Address - Country:US
Mailing Address - Phone:760-585-5571
Mailing Address - Fax:760-753-7259
Practice Address - Street 1:5202 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-2268
Practice Address - Country:US
Practice Address - Phone:619-208-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA631459163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse