Provider Demographics
NPI:1730815879
Name:FULLWOOD, DEANDRE CLAUDE (LPN)
Entity type:Individual
Prefix:MR
First Name:DEANDRE
Middle Name:CLAUDE
Last Name:FULLWOOD
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16894 73RD CT N # CTN
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-5838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8841 LYNDALL LN
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1639
Practice Address - Country:US
Practice Address - Phone:561-631-9997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL855671207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine