Healthcare Provider Details

I. General information

NPI: 1922244151
Provider Name (Legal Business Name): YVONNE FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MARTINDALE RD
LAKE GEORGE NY
12845-4515
US

IV. Provider business mailing address

14 MARTINDALE RD
LAKE GEORGE NY
12845-4515
US

V. Phone/Fax

Practice location:
  • Phone: 518-743-9759
  • Fax:
Mailing address:
  • Phone: 518-743-9759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number011403
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: