Individual
CARLY FAITH FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2300 OPITZ BLVD, WOODBRIDGE, VA 22191-3311
(703) 915-5550
Mailing address
2151 OLD BRICK RD, GLEN ALLEN, VA 23060-5837
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0110007223
VA
363AM0700X
Medical Physician Assistant
Primary
0110007223
VA
Other
Enumeration date
03/05/2019
Last updated
12/29/2022
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