Provider Demographics
NPI:1942555404
Name:FULLER, RENEIGH MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:RENEIGH
Middle Name:MARIE
Last Name:FULLER
Suffix:
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 1:2405 CHEYENNE BLVD
Mailing Address - Street 2:118
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1767
Mailing Address - Country:US
Mailing Address - Phone:567-230-9844
Mailing Address - Fax:
Practice Address - Street 1:2405 CHEYENNE BLVD
Practice Address - Street 2:118
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1767
Practice Address - Country:US
Practice Address - Phone:567-230-9844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN123884164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse