Healthcare Provider Details

I. General information

NPI: 1154094480
Provider Name (Legal Business Name): HADLEY MAYES UNGER FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

IV. Provider business mailing address

2640 MARTIN LUTHER KING JR WAY
BERKELEY CA
94704-3238
US

V. Phone/Fax

Practice location:
  • Phone: 651-276-5115
  • Fax:
Mailing address:
  • Phone: 651-276-5115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: