Provider Demographics
NPI:1023487592
Name:FULLER, LINDSEY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10603 WILD FLOWER PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1687
Mailing Address - Country:US
Mailing Address - Phone:260-705-7098
Mailing Address - Fax:
Practice Address - Street 1:10603 WILD FLOWER PL
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1687
Practice Address - Country:US
Practice Address - Phone:260-705-7098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005064A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN06005064AOtherPHYSICAL THERAPY COMMITTEE