Basic Information
| Provider Information | |||||||||
| NPI: | 1619577103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | GENA | ||||||||
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| Credential: | ATC/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 VOIGHT AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038148108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4675 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066061813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033730551 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2020 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 1026 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 1026 | 01 | CT | STATE LICENSE | OTHER |