Provider Demographics
NPI:1962276055
Name:FULLER, APOLLONIA (PBT)
Entity type:Individual
Prefix:
First Name:APOLLONIA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-1166
Mailing Address - Country:US
Mailing Address - Phone:217-870-1126
Mailing Address - Fax:
Practice Address - Street 1:903 N UNION ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-1166
Practice Address - Country:US
Practice Address - Phone:217-870-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IL273111646420971246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy