Provider Demographics
NPI:1144738741
Name:FULMER, KRISTEN LYNN (MS RD CD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNN
Last Name:FULMER
Suffix:
Gender:F
Credentials:MS RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7884
Mailing Address - Country:US
Mailing Address - Phone:262-948-6692
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-646-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3041-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered