Provider Demographics
NPI:1104695907
Name:FULLER, ADRIENNE DORIES
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:DORIES
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 1:208 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-1702
Mailing Address - Country:US
Mailing Address - Phone:910-760-5017
Mailing Address - Fax:
Practice Address - Street 1:1701 CENTER ST
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-7026
Practice Address - Country:US
Practice Address - Phone:984-246-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician