Individual
MIMI O FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CNA
Contact information
Practice address
735 E MAIN STREET, SPARTANBURG, SC 29302-1281
(864) 542-1308
Mailing address
735 E MAIN STREET, SPARTANBURG, SC 29302-1281
(864) 542-1308
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
AANA22356
SC
367500000X
Certified Registered Nurse Anesthetist
Primary
SCAPN987
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
AN0665
—
SC
Enumeration date
08/25/2006
Last updated
10/25/2007
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