Healthcare Provider Details

I. General information

NPI: 1336457894
Provider Name (Legal Business Name): ERIN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 GRAND ISLAND BLVD
GRAND ISLAND NY
14072-2249
US

IV. Provider business mailing address

1801 GRAND ISLAND BLVD
GRAND ISLAND NY
14072-2249
US

V. Phone/Fax

Practice location:
  • Phone: 716-773-4323
  • Fax:
Mailing address:
  • Phone: 716-773-4323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number004823-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: