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Individual

JALISA FULLER

Active
Sole proprietor
No

Provider details

NPI number
Gender
F

Contact information

Practice address
1621 WILLIAMSBURG DR, BOSSIER CITY, LA 71112-3165
(318) 730-2368
Mailing address
1621 WILLIAMSBURG DR, BOSSIER CITY, LA 71112-3165
(318) 730-2368

Taxonomy

Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
009494849
LA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
843382246
LA
Enumeration date
05/28/2021
Last updated
05/28/2021
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Product
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