Provider Demographics
NPI:1093138158
Name:FULLER, KAITLYN (DPT)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 N LAMAR BLVD STE A114
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-1049
Mailing Address - Country:US
Mailing Address - Phone:512-646-4673
Mailing Address - Fax:512-729-0320
Practice Address - Street 1:7801 N LAMAR BLVD STE E216
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-1020
Practice Address - Country:US
Practice Address - Phone:512-646-4673
Practice Address - Fax:310-882-5451
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298008225100000X
NY036493225100000X
TX3125524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist