Provider Demographics
NPI:1821860974
Name:VALDIVIA FULLER, MARIA GUADALUPE
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:GUADALUPE
Last Name:VALDIVIA 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 1:1139 W HILL DR # D
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2967
Mailing Address - Country:US
Mailing Address - Phone:213-318-9778
Mailing Address - Fax:
Practice Address - Street 1:10801 6TH ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5977
Practice Address - Country:US
Practice Address - Phone:909-819-8761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker