Individual
CRYSTAL MARY AGATHA FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LDO, ABOC, NCLEC
Contact information
Practice address
3068 COTTON INDIAN CIR, ELLENWOOD, GA 30294-3587
(404) 824-8261
(770) 719-4392
Mailing address
3068 COTTON INDIAN CIR, ELLENWOOD, GA 30294-3587
(404) 824-8261
(770) 719-4392
Taxonomy
Speciality
Code
Description
License number
State
156FX1800X
Optician
Primary
2429
GA
Other
Enumeration date
09/27/2024
Last updated
09/27/2024
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