Provider Demographics
NPI:1811368004
Name:FULLER, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:4451 E FRANCES RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-8854
Mailing Address - Country:US
Mailing Address - Phone:810-293-0137
Mailing Address - Fax:
Practice Address - Street 1:4451 E FRANCES RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-8854
Practice Address - Country:US
Practice Address - Phone:810-293-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide