Provider Demographics
NPI:1306346184
Name:FULLER, JOHNNY RAY (LVN)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
Last Name:FULLER
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 COUNTY ROAD 1165
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-6930
Mailing Address - Country:US
Mailing Address - Phone:936-332-3232
Mailing Address - Fax:936-332-3232
Practice Address - Street 1:131 COUNTY ROAD 3102
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-5581
Practice Address - Country:US
Practice Address - Phone:936-591-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2018-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206588164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse