Provider Demographics
NPI:1285139477
Name:FULLER, PHILECIA RENEE (HOME CARE PROVIDER)
Entity type:Individual
Prefix:MS
First Name:PHILECIA
Middle Name:RENEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:HOME CARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LAKEWOOD DR APT H4
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-1838
Mailing Address - Country:US
Mailing Address - Phone:334-408-8115
Mailing Address - Fax:
Practice Address - Street 1:1800 LAKEWOOD DR APT H4
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-1838
Practice Address - Country:US
Practice Address - Phone:334-408-8115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care