Provider Demographics
NPI:1902020290
Name:FULLBRIGHT, LORRAINE
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:FULLBRIGHT
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:PO BOX 671750
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-1750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18606 OLD GLENN HIGHWAY
Practice Address - Street 2:
Practice Address - City:CHUGIAK
Practice Address - State:AK
Practice Address - Zip Code:99567
Practice Address - Country:US
Practice Address - Phone:907-688-0282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCM6474171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM6474Medicaid