Provider Demographics
NPI:1770397184
Name:FULLER, TRACEY L
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:FULLER
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 1:1255 S MONROE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3054
Mailing Address - Country:US
Mailing Address - Phone:920-246-9710
Mailing Address - Fax:
Practice Address - Street 1:1255 S MONROE AVE STE 102
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3054
Practice Address - Country:US
Practice Address - Phone:920-246-9710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier