Provider Demographics
NPI:1821696196
Name:FULLARD, LACREASHA (CRNP-PMH)
Entity Type:Individual
Prefix:MRS
First Name:LACREASHA
Middle Name:
Last Name:FULLARD
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9649 BELAIR RD STE 104
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1117
Mailing Address - Country:US
Mailing Address - Phone:410-529-1309
Mailing Address - Fax:410-529-1005
Practice Address - Street 1:9649 BELAIR RD STE 104
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1117
Practice Address - Country:US
Practice Address - Phone:410-529-1309
Practice Address - Fax:410-529-1005
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR219476363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health