Provider Demographics
NPI:1700073673
Name:FULLER, AMY BETH (RD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:FULLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:BETH
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1081 N CHINA LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3130
Mailing Address - Country:US
Mailing Address - Phone:760-499-3781
Mailing Address - Fax:760-446-3551
Practice Address - Street 1:1081 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3130
Practice Address - Country:US
Practice Address - Phone:760-499-3781
Practice Address - Fax:760-446-3551
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
710033133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered