Provider Demographics
NPI:1902976863
Name:FULLER TERRY, A NEDRA YULONDA (DPM)
Entity Type:Individual
Prefix:DR
First Name:A NEDRA
Middle Name:YULONDA
Last Name:FULLER TERRY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:A NEDRA
Other - Middle Name:YULONDA
Other - Last Name:FULLER TERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2828 FIRST AVENUE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1236
Mailing Address - Country:US
Mailing Address - Phone:304-522-3692
Mailing Address - Fax:304-522-3693
Practice Address - Street 1:2828 FIRST AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1236
Practice Address - Country:US
Practice Address - Phone:304-522-3692
Practice Address - Fax:304-522-3693
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10387213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00357027OtherRR MEDICARE
WV3810007238Medicaid
OH2707084Medicaid
WV3810007238Medicaid
WVV10517Medicare UPIN