Provider Demographics
NPI:1316410368
Name:FULLER, KASSY JO (DC)
Entity Type:Individual
Prefix:
First Name:KASSY
Middle Name:JO
Last Name:FULLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21513 48TH AVE W APT C201
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5957
Mailing Address - Country:US
Mailing Address - Phone:920-615-4912
Mailing Address - Fax:
Practice Address - Street 1:8325 212TH ST SW STE 103
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7435
Practice Address - Country:US
Practice Address - Phone:425-776-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60892858111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60892858OtherCHIROPRACTIC LICENSE