Provider Demographics
NPI:1578678199
Name:FULLER, REBECCA WHEAT (RDLD)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:WHEAT
Last Name:FULLER
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 COUNTRY CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3910
Mailing Address - Country:US
Mailing Address - Phone:281-242-2368
Mailing Address - Fax:281-242-7894
Practice Address - Street 1:1930 COUNTRY CLUB BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3910
Practice Address - Country:US
Practice Address - Phone:281-242-2368
Practice Address - Fax:281-242-7894
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04457133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT04457OtherLD NUMBER