Provider Demographics
NPI:1427878016
Name:FULLER, CAROLYN ANNE
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANNE
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 1:909 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-2716
Mailing Address - Country:US
Mailing Address - Phone:304-922-8705
Mailing Address - Fax:
Practice Address - Street 1:909 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-2716
Practice Address - Country:US
Practice Address - Phone:304-922-8705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency