Gena Fuller, ATC/L

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

1026 Issued in CT

Practice address

4675 Main St
Bridgeport, CT 06606-1813

Phone

(203) 373-0551

NPI assigned

Oct 26, 2020

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Interoperability endpoints

• Direct secure messaging: genfuller@selectmedical.com

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1603670400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1701043200000",
    "number": "1619577103",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "35 VOIGHT AVE",
            "city": "BRIDGEPORT",
            "state": "CT",
            "postal_code": "066061537",
            "telephone_number": "203-814-8108"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4675 MAIN ST",
            "city": "BRIDGEPORT",
            "state": "CT",
            "postal_code": "066061813",
            "telephone_number": "203-373-0551"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "GENA",
        "credential": "ATC/L",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2020-10-26",
        "last_updated": "2023-11-27",
        "certification_date": "2020-08-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "CT",
            "license": "1026",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE LICENSE",
            "identifier": "1026",
            "state": "CT"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "GenFuller@selectmedical.com",
            "affiliation": "Y",
            "endpointDescription": "Work Email",
            "affiliationName": "Select Physical Therapy",
            "address_1": "4675 Main St",
            "city": "Bridgeport",
            "state": "CT",
            "country_code": "US",
            "postal_code": "066061813",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Athletic Trainer in Bridgeport, CT
• Providers in Bridgeport, CT by specialty
• Athletic Trainer in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.