Provider Demographics
NPI:1033354352
Name:FULLER, KELLIE L (CMT,LMT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:CMT,LMT
Other - Prefix:
Other - First Name:KELIE
Other - Middle Name:L
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:626 E MAIN ST # 2
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2714
Mailing Address - Country:US
Mailing Address - Phone:505-608-9908
Mailing Address - Fax:
Practice Address - Street 1:626 E MAIN ST # 2
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2714
Practice Address - Country:US
Practice Address - Phone:505-608-9908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5427225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist