Healthcare Provider Details

I. General information

NPI: 1922931872
Provider Name (Legal Business Name): IMONNI J FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W BEDFORD AVE STE 105D
FRESNO CA
93711-5819
US

IV. Provider business mailing address

1099 E CHAMPLAIN DR # A1151
FRESNO CA
93720-5030
US

V. Phone/Fax

Practice location:
  • Phone: 559-633-9030
  • Fax:
Mailing address:
  • Phone: 559-663-9030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number147623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: