Provider Demographics
NPI:1336838267
Name:FULLER, TERRELL A (LPN)
Entity Type:Individual
Prefix:MISS
First Name:TERRELL
Middle Name:A
Last Name:FULLER
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 1:850 STEPHENSON HWY STE 612
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1127
Mailing Address - Country:US
Mailing Address - Phone:888-451-2519
Mailing Address - Fax:
Practice Address - Street 1:561 IRVINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-3103
Practice Address - Country:US
Practice Address - Phone:973-373-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP53855164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse