Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1003393653 |
---|---|
Provider Name | Teri Fullmer |
First Address | Boise, ID 83704-5003 |
Second Address | Boise, ID 83704-5003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2018 |
Last Update Date | 26/07/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
065186 | ABO (01) |