Healthcare Provider Details

I. General information

NPI: 1962489229
Provider Name (Legal Business Name): LESLIE E FULLER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BLAKE AVE
GLENWOOD SPGS CO
81601-4227
US

IV. Provider business mailing address

PO BOX 932
GLENWOOD SPGS CO
81602-0932
US

V. Phone/Fax

Practice location:
  • Phone: 970-945-6535
  • Fax:
Mailing address:
  • Phone: 970-945-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number32980
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: