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General NPI Number Information
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NPI Number | 1912320334
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Entity Type | Individual
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Provider Name | MR. CHRISTOPHER MARSHALL FULLER
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Gender | Male
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Dates
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Enumeration Date | 01/22/2014
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Last Update Date | 01/22/2014
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Provider Practice Location Address
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Address Line | 5132 EDGEWARE CT.
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City | JACKSONVILLE
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State | FL
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Zip | 32217
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Country | US
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Telephone | 904-874-1761
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Fax |
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Provider Business Mailing Address
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Address Line | 5132 EDGEWARE CT.
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City | JACKSONVILLE
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State | FL
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Zip | 32217
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Country | US
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Telephone | 904-874-1761
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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 | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number | F460-113-89-031-0
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License Number State | FL
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