Provider Demographics
NPI:1740019561
Name:FULLER-DOUGLAS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FULLER-DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 APPLE TREE DR
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-7506
Mailing Address - Country:US
Mailing Address - Phone:616-527-1790
Mailing Address - Fax:616-527-0538
Practice Address - Street 1:375 APPLE TREE DR
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-7506
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:616-527-0538
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023748101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional