Provider Demographics
NPI:1013518695
Name:FULLER, ADONNA
Entity type:Individual
Prefix:
First Name:ADONNA
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 1:5613 DERBY FIELD LN UNIT 201
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-2069
Mailing Address - Country:US
Mailing Address - Phone:614-787-3299
Mailing Address - Fax:
Practice Address - Street 1:14O IMPERIAL DRIVE
Practice Address - Street 2:APT 120
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-787-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH015675Medicaid