Healthcare Provider Details

I. General information

NPI: 1295649887
Provider Name (Legal Business Name): CORRAE QUANELLIA FULLWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MARION YOUNG CT
AIKEN SC
29801-9534
US

IV. Provider business mailing address

2180 OLD C C RD
LYNCHBURG SC
29080-8712
US

V. Phone/Fax

Practice location:
  • Phone: 803-646-2735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: