Individual
DIANA FULLER,MICOU
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
825 JAMES H MEREDITH ST, KOSCIUSKO, MS 39090-3161
(662) 289-3699
Mailing address
825 JAMES H MEREDITH ST, KOSCIUSKO, MS 39090-3161
Taxonomy
Speciality
Code
Description
License number
State
251V00000X
Voluntary or Charitable Agency
Primary
—
—
Other
Enumeration date
10/26/2017
Last updated
10/26/2017
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