Provider Demographics
NPI:1013113133
Name:FULLER, MARY ANN (RD LD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:WISDOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDLD
Mailing Address - Street 1:415 SPRINGTREE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75065-2392
Mailing Address - Country:US
Mailing Address - Phone:214-725-9702
Mailing Address - Fax:
Practice Address - Street 1:415 SPRINGTREE RD
Practice Address - Street 2:
Practice Address - City:LAKE DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75065-2392
Practice Address - Country:US
Practice Address - Phone:214-725-9702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05158133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered