Provider Demographics
NPI:1295331080
Name:FULLER, LAQUALYN
Entity type:Individual
Prefix:
First Name:LAQUALYN
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 1:4111 HELENA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-1206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4111 HELENA AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-1206
Practice Address - Country:US
Practice Address - Phone:330-519-0964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174200000X, 251E00000X, 251J00000X, 347C00000X, 372500000X, 376J00000X
OH174238164X00000X
OHLPN.174238164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No174200000XOther Service ProvidersMeals
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No347C00000XTransportation ServicesPrivate Vehicle
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker