Healthcare Provider Details

I. General information

NPI: 1336385228
Provider Name (Legal Business Name): MRS. CHRISTINA LAUREN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

6716 PLEASANT DR
CHARLOTTE NC
28211-4734
US

V. Phone/Fax

Practice location:
  • Phone: 864-680-9674
  • Fax:
Mailing address:
  • Phone: 864-680-9674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number080644
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: