Individual
GENA FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
ATC/L
Contact information
Practice address
4675 MAIN ST, BRIDGEPORT, CT 06606-1813
(203) 373-0551
Mailing address
35 VOIGHT AVE, BRIDGEPORT, CT 06606-1537
(203) 814-8108
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
1026
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1026
STATE LICENSE
CT
Enumeration date
10/26/2020
Last updated
11/27/2023
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