Healthcare Provider Details

I. General information

NPI: 1295331080
Provider Name (Legal Business Name): LAQUALYN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 HELENA AVE
YOUNGSTOWN OH
44512-1206
US

IV. Provider business mailing address

4111 HELENA AVE
YOUNGSTOWN OH
44512-1206
US

V. Phone/Fax

Practice location:
  • Phone: 330-519-0964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number174238
License Number StateOH
# 6
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.174238
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.554497
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: