Provider Demographics
NPI:1801193669
Name:FULLERTON-HENRY, TANYA MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:MARIE
Last Name:FULLERTON-HENRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2460
Mailing Address - Country:US
Mailing Address - Phone:216-215-7182
Mailing Address - Fax:
Practice Address - Street 1:1424 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2460
Practice Address - Country:US
Practice Address - Phone:216-215-7182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129947164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse