Provider Demographics
NPI:1205257474
Name:FULLER, LINDSAY
Entity type:Individual
Prefix:
First Name:LINDSAY
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 1:900 N. KINGSBURY RIVERWALK 6-A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610
Mailing Address - Country:US
Mailing Address - Phone:312-321-0004
Mailing Address - Fax:
Practice Address - Street 1:900 N. KINGSBURY RIVERWALK 6-A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610
Practice Address - Country:US
Practice Address - Phone:312-321-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.016323225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist