Provider Demographics
NPI:1538367859
Name:THOMAS-FULLER, LATASHA A
Entity type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:A
Last Name:THOMAS-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 1:79 GUILFORD CT
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-7058
Mailing Address - Country:US
Mailing Address - Phone:910-497-0002
Mailing Address - Fax:
Practice Address - Street 1:79 GUILFORD CT
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-7058
Practice Address - Country:US
Practice Address - Phone:910-497-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-09
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408062Medicaid