Provider Demographics
NPI:1396629077
Name:FULLER, GLENDA (LMT)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 ROLLING OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6806
Mailing Address - Country:US
Mailing Address - Phone:501-333-4433
Mailing Address - Fax:
Practice Address - Street 1:9224 MAUMELLE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72113-6678
Practice Address - Country:US
Practice Address - Phone:501-333-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4226225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist