Provider Demographics
NPI:1073064473
Name:FULLER, BRYNN (MS ATC)
Entity Type:Individual
Prefix:MRS
First Name:BRYNN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS ATC
Other - Prefix:
Other - First Name:BRYNN
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:994 56TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-3132
Mailing Address - Country:US
Mailing Address - Phone:206-310-7369
Mailing Address - Fax:
Practice Address - Street 1:1101 MADISON ST STE 800
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1307
Practice Address - Country:US
Practice Address - Phone:206-316-3083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1608600962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer