Provider Demographics
NPI:1841162310
Name:FULLER, RYAN CHANDLER
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:CHANDLER
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 VILLAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3626
Mailing Address - Country:US
Mailing Address - Phone:336-793-7297
Mailing Address - Fax:
Practice Address - Street 1:148 WIND CHIME CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6581
Practice Address - Country:US
Practice Address - Phone:919-263-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20648A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist