Provider Demographics
NPI:1396079919
Name:FULLER, LESLIE ERIN (ND)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ERIN
Last Name:FULLER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3519
Mailing Address - Country:US
Mailing Address - Phone:503-372-5147
Mailing Address - Fax:
Practice Address - Street 1:27501 SW 95TH AVE STE 960
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-7713
Practice Address - Country:US
Practice Address - Phone:503-372-5147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1692175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath