Provider Demographics
NPI:1891579231
Name:FULLER, BREANNA MARIA
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:MARIA
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 1:400 INDIAN RUN RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19311-1509
Mailing Address - Country:US
Mailing Address - Phone:443-752-9120
Mailing Address - Fax:
Practice Address - Street 1:400 INDIAN RUN RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:PA
Practice Address - Zip Code:19311-1509
Practice Address - Country:US
Practice Address - Phone:443-752-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer