Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 63479 | MN |
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | A160366 | CA |
NPI | 1902149933 |
---|---|
Provider Name | Jennifer Carroll Fuller |
First Address | Loma Linda, CA 92354-2804 |
Second Address | Loma Linda, CA 92354-2804 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2013 |
Last Update Date | 10/07/2019 |