Basic Information
| Provider Information | |||||||||
| NPI: | 1417486184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | CHIQUITA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 GA HIGHWAY 96 | ||||||||
| Address2: | STE C | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789887100 | ||||||||
| FaxNumber: | 4789888098 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 GA HIGHWAY 96 STE C | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310882585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789887100 | ||||||||
| FaxNumber: | 4789888098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747A0650X | Y | Nursing Service Related Providers | Technician | Attendant Care Provider |
No ID Information.