Provider Demographics
NPI:1912925298
Name:FULLER, SHANDA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANDA
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 SYCAMORE VALLEY RD W
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-3900
Mailing Address - Country:US
Mailing Address - Phone:925-837-5595
Mailing Address - Fax:925-837-6558
Practice Address - Street 1:565 SYCAMORE VALLEY RD W
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-3900
Practice Address - Country:US
Practice Address - Phone:925-837-5595
Practice Address - Fax:925-837-6558
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0272880Medicare UPIN