Individual
DESTINY FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
1389 JACKSON ST, MACON, GA 31201-2207
(478) 305-9558
Mailing address
1389 JACKSON ST, MACON, GA 31201-2207
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
LPN098619
GA
Other
Enumeration date
12/03/2020
Last updated
12/03/2020
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