Basic Information
| Provider Information | |||||||||
| NPI: | 1134668213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | GWEN | ||||||||
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| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 867 | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845010867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Practice Location | |||||||||
| Address1: | 198 EAST CENTER STREET | ||||||||
| Address2: | |||||||||
| City: | MOAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352596131 | ||||||||
| FaxNumber: | 4352595369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2017 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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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 | 164W00000X | 9826037-3101 | UT | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.