Provider Demographics
NPI:1417741208
Name:FULLER, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FULLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 WINTERCREEK CIR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8867
Mailing Address - Country:US
Mailing Address - Phone:330-810-7025
Mailing Address - Fax:
Practice Address - Street 1:332 WINTERCREEK CIR
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8867
Practice Address - Country:US
Practice Address - Phone:330-810-7025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker