Healthcare Provider Details

I. General information

NPI: 1275176901
Provider Name (Legal Business Name): PATRICIA LYNN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PATRICIA LYNN MCGUFF

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3554 WESTWOOD RD NE
MANCELONA MI
49659-9539
US

IV. Provider business mailing address

3554 WESTWOOD RD NE
MANCELONA MI
49659-9539
US

V. Phone/Fax

Practice location:
  • Phone: 231-676-9859
  • Fax: 231-916-2347
Mailing address:
  • Phone: 231-676-9859
  • Fax: 231-916-2347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number802059811
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: