Provider Demographics
NPI:1902686819
Name:FULLER, CATHY JEAN
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:JEAN
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6586 HWY 40
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4039
Mailing Address - Country:US
Mailing Address - Phone:912-464-4986
Mailing Address - Fax:912-510-9202
Practice Address - Street 1:6586 HWY 40
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-4039
Practice Address - Country:US
Practice Address - Phone:912-464-4986
Practice Address - Fax:912-510-9202
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician