Healthcare Provider Details

I. General information

NPI: 1154398725
Provider Name (Legal Business Name): BARBARA B FULLER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 MCLEOD RD NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 29269
SANTA FE NM
87592-9269
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-2032
  • Fax: 505-837-2030
Mailing address:
  • Phone: 505-984-2032
  • Fax: 505-474-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number255
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: