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General NPI Number Information
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NPI Number | 1790046654
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Entity Type | Individual
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Provider Name | MR. AUNDRA LAMAR FULLER
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Gender | Male
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Dates
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Enumeration Date | 06/06/2012
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Last Update Date | 06/06/2012
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Provider Practice Location Address
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Address Line | 10922 E. 39TH ST.
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City | TULSA
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State | OK
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Zip | 74146
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Country | US
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Telephone | 918-282-6850
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Fax |
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Provider Business Mailing Address
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Address Line | 10922 E 39TH ST
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City | TULSA
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State | OK
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Zip | 74146-2703
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Country | US
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Telephone | 918-282-6850
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 99999999999999999999
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | 99999999999999999999
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License Number State | OK
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