Provider Demographics
NPI:1912725060
Name:FULLER, CRYSTAL MARY AGATHA (LDO, ABOC, NCLEC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARY AGATHA
Last Name:FULLER
Suffix:
Gender:F
Credentials:LDO, ABOC, NCLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3068 COTTON INDIAN CIR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3587
Mailing Address - Country:US
Mailing Address - Phone:404-824-8261
Mailing Address - Fax:770-719-4392
Practice Address - Street 1:3068 COTTON INDIAN CIR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3587
Practice Address - Country:US
Practice Address - Phone:404-824-8261
Practice Address - Fax:770-719-4392
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2429156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician