=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326370727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADINE MARIE FULLE LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2010
-----------------------------------------------------
Last Update Date | 02/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2341 BOWEN RD
-----------------------------------------------------
City | ELMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14059-9415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-655-3129
-----------------------------------------------------
Fax | 716-655-4008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2341 BOWEN RD PO BOX 182
-----------------------------------------------------
City | ELMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14059-9415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-655-3129
-----------------------------------------------------
Fax | 716-655-4008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0235271
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------