Provider Demographics
NPI:1043024334
Name:FULLER, ANGEL TIFFANY
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:TIFFANY
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WENHAM WAY
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-3491
Mailing Address - Country:US
Mailing Address - Phone:214-309-6206
Mailing Address - Fax:
Practice Address - Street 1:121 WENHAM WAY
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-3491
Practice Address - Country:US
Practice Address - Phone:214-309-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty