Provider Demographics
NPI:1538964150
Name:FULLERS PLACE
Entity type:Organization
Organization Name:FULLERS PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:347-300-5858
Mailing Address - Street 1:1102 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4304
Mailing Address - Country:US
Mailing Address - Phone:347-300-5858
Mailing Address - Fax:
Practice Address - Street 1:445 PARK AVE FL 990167
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2606
Practice Address - Country:US
Practice Address - Phone:347-300-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty