Provider Demographics
NPI:1952124091
Name:FULLER, ANTONETTE
Entity type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:
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 1:2639 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2639 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2023
Practice Address - Country:US
Practice Address - Phone:860-659-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14117363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily