Provider Demographics
NPI:1811231384
Name:FULLER, LUCINDY THOMASINA
Entity Type:Individual
Prefix:MS
First Name:LUCINDY
Middle Name:THOMASINA
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 1:4364 TARA AVE APT D
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-7406
Mailing Address - Country:US
Mailing Address - Phone:909-658-9407
Mailing Address - Fax:
Practice Address - Street 1:1265 KENDALL DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407
Practice Address - Country:US
Practice Address - Phone:909-545-1867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner