Provider Demographics
NPI:1780150011
Name:FULLER, MARTIA JERONDA
Entity type:Individual
Prefix:
First Name:MARTIA
Middle Name:JERONDA
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 1:204 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-3625
Mailing Address - Country:US
Mailing Address - Phone:919-339-0649
Mailing Address - Fax:
Practice Address - Street 1:8401 MEDICAL PLAZA DR STE 360
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8700
Practice Address - Country:US
Practice Address - Phone:704-208-4458
Practice Address - Fax:866-309-6385
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-14
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14117101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty