Provider Demographics
NPI:1053299719
Name:FULLER, AINSLEY JO'ALISE
Entity type:Individual
Prefix:
First Name:AINSLEY
Middle Name:JO'ALISE
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 1:704 PACKARD ST NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-3127
Mailing Address - Country:US
Mailing Address - Phone:330-979-0478
Mailing Address - Fax:
Practice Address - Street 1:704 PACKARD ST NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3127
Practice Address - Country:US
Practice Address - Phone:330-979-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20252883P374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide