Provider Demographics
NPI:1922429521
Name:FULLWOOD, SARINA
Entity Type:Individual
Prefix:
First Name:SARINA
Middle Name:
Last Name:FULLWOOD
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 1:1097 NUGENT AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1339
Mailing Address - Country:US
Mailing Address - Phone:631-894-6760
Mailing Address - Fax:
Practice Address - Street 1:1097 NUGENT AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1339
Practice Address - Country:US
Practice Address - Phone:631-894-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315603-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse