=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376724211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA JUDITH FULLER LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2007
-----------------------------------------------------
Last Update Date | 11/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 E MAIN ST
-----------------------------------------------------
City | HORNELL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14843-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-201-6166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 HUGHES ST E PO BOX 316
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14711-8725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-201-6166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3140N1450X
-----------------------------------------------------
Taxonomy Name | Pediatric Skilled Nursing Facility
-----------------------------------------------------
License Number | 217696-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------