Provider Demographics
NPI:1801246210
Name:FULLER, LISA (RN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LEE
Other - Last Name:TASONIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 LAURIE LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-3539
Mailing Address - Country:US
Mailing Address - Phone:339-499-8026
Mailing Address - Fax:
Practice Address - Street 1:25 LAURIE LN
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02324-3539
Practice Address - Country:US
Practice Address - Phone:339-499-8026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217160163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management