Provider Demographics
NPI:1104217033
Name:FULLER, STEPHEN (LMP)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22021 7TH AVE S
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6218
Mailing Address - Country:US
Mailing Address - Phone:206-429-2782
Mailing Address - Fax:
Practice Address - Street 1:22021 7TH AVE S
Practice Address - Street 2:SUITE 3
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6218
Practice Address - Country:US
Practice Address - Phone:206-429-2782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60015141225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist