Provider Demographics
NPI:1740943828
Name:FULLER, AUDREY BEATRICE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:BEATRICE
Last Name:FULLER
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 ENCLAVE PARIS DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-1345
Mailing Address - Country:US
Mailing Address - Phone:717-565-0064
Mailing Address - Fax:
Practice Address - Street 1:1203 ENCLAVE PARIS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-1345
Practice Address - Country:US
Practice Address - Phone:717-565-0064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86107559133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered