Provider Demographics
NPI:1831617646
Name:FULLER, REBECCA LYNN (RD, CDN)
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 RITA DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3229 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-2016
Practice Address - Country:US
Practice Address - Phone:917-455-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009116-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered