Provider Demographics
NPI:1861147753
Name:FULLER, ALICE C
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:C
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 SUDDERTH DR STE B
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6338
Mailing Address - Country:US
Mailing Address - Phone:575-491-3300
Mailing Address - Fax:505-420-6034
Practice Address - Street 1:2904 SUDDERTH DR STE B
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6338
Practice Address - Country:US
Practice Address - Phone:575-491-3300
Practice Address - Fax:505-420-6034
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker