Provider Demographics
NPI:1780578773
Name:FULLER, LACEY (LMT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 MARKS RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:ME
Mailing Address - Zip Code:04910-6934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:173 MARKS RD
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:ME
Practice Address - Zip Code:04910-6934
Practice Address - Country:US
Practice Address - Phone:207-250-3169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT7533225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist