Provider Demographics
NPI:1912320334
Name:FULLER, CHRISTOPHER MARSHALL
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:MARSHALL
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:CHRISTOPHER
Other - Middle Name:MARSHALL
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:5132 EDGEWARE CT.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217
Mailing Address - Country:US
Mailing Address - Phone:904-874-1761
Mailing Address - Fax:
Practice Address - Street 1:5132 EDGEWARE CT.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217
Practice Address - Country:US
Practice Address - Phone:904-874-1761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF460-113-89-031-0222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist