Provider Demographics
NPI:1336572429
Name:FULLER-RICHARDSON, NICOLE YVETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:YVETTE
Last Name:FULLER-RICHARDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 WESTSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5442
Mailing Address - Country:US
Mailing Address - Phone:516-322-0727
Mailing Address - Fax:516-377-1637
Practice Address - Street 1:134 WESTSIDE AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-5442
Practice Address - Country:US
Practice Address - Phone:516-322-0727
Practice Address - Fax:516-377-1637
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262710-1164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse