Provider Demographics
NPI:1518851344
Name:FULLER, JEREMIEH LYNN
Entity type:Individual
Prefix:
First Name:JEREMIEH
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:SOD
Mailing Address - State:WV
Mailing Address - Zip Code:25564-0207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1644 GARRETTS BND
Practice Address - Street 2:
Practice Address - City:SOD
Practice Address - State:WV
Practice Address - Zip Code:25564-7506
Practice Address - Country:US
Practice Address - Phone:304-444-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide