Provider Demographics
NPI:1255431037
Name:FULLERTON, JOHN REYNOLDS (DED)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:REYNOLDS
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:DED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 TIMBER VILLA
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-9223
Mailing Address - Country:US
Mailing Address - Phone:717-367-1005
Mailing Address - Fax:
Practice Address - Street 1:VA MEDICAL CENTER (620)
Practice Address - Street 2:1700 LINCOLN AVENUE
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-0000
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS001071L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist