Provider Demographics
NPI:1528322963
Name:FULLER, GRETA JANET (DOM, LAC)
Entity type:Individual
Prefix:DR
First Name:GRETA
Middle Name:JANET
Last Name:FULLER
Suffix:
Gender:F
Credentials:DOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2401 BRANDERMILL BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1604
Mailing Address - Country:US
Mailing Address - Phone:410-774-0800
Mailing Address - Fax:410-774-0799
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1604
Practice Address - Country:US
Practice Address - Phone:410-774-0800
Practice Address - Fax:410-774-0799
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDU01901171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist