1306051222 NPI number — NANCY C FULLER D. C.

Table of content: NANCY C FULLER D. C. (NPI 1306051222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306051222 NPI number — NANCY C FULLER D. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
NANCY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D. C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALLEGARI
Provider Other First Name:
NANCY
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D. C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306051222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 CANADA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWANTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05488-1322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-868-7725
Provider Business Mailing Address Fax Number:
802-868-3703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 ROBIN HOOD DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SWANTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05488-8003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-868-7725
Provider Business Practice Location Address Fax Number:
802-868-3703
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0060000713 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1012108 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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