Provider Demographics
NPI:1093189987
Name:FULLER, KIERSTEN
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 E 500 S
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3939
Mailing Address - Country:US
Mailing Address - Phone:435-503-5643
Mailing Address - Fax:
Practice Address - Street 1:989 E 500 S
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3939
Practice Address - Country:US
Practice Address - Phone:435-503-5643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1194007724OtherMEDICARE UPIN,MEDICARE PIN, MEDICARE OSCAR/CERTIFICATION, MEDICARE NSC, MEDICAID