Provider Demographics
NPI:1922521277
Name:FULLER, MARSHA ANN I (LPN)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:ANN
Last Name:FULLER
Suffix:I
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 ROWLEE RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-4228
Mailing Address - Country:US
Mailing Address - Phone:315-439-4397
Mailing Address - Fax:
Practice Address - Street 1:867 ROWLEE RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-4228
Practice Address - Country:US
Practice Address - Phone:315-439-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299221-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY299221-1OtherNYS