Provider Demographics
NPI:1922244151
Name:FULLER, YVONNE
Entity Type:Individual
Prefix:
First Name:YVONNE
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 1:14 MARTINDALE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-4515
Mailing Address - Country:US
Mailing Address - Phone:518-743-9759
Mailing Address - Fax:
Practice Address - Street 1:14 MARTINDALE RD
Practice Address - Street 2:
Practice Address - City:LAKE GEORGE
Practice Address - State:NY
Practice Address - Zip Code:12845-4515
Practice Address - Country:US
Practice Address - Phone:518-743-9759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011403225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist