Provider Demographics
NPI:1124509831
Name:FULLER, SHARON D
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:D
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 1:2611 LAMAR CT
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-8487
Mailing Address - Country:US
Mailing Address - Phone:843-453-6525
Mailing Address - Fax:
Practice Address - Street 1:2611 LAMAR CT
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-8487
Practice Address - Country:US
Practice Address - Phone:843-453-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC83-1588651OtherTAX ID