Provider Demographics
NPI:1336643840
Name:FULLER, LASONDRA (LMT)
Entity Type:Individual
Prefix:
First Name:LASONDRA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N 3RD AVE SW UNIT A
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6404
Mailing Address - Country:US
Mailing Address - Phone:253-442-4514
Mailing Address - Fax:
Practice Address - Street 1:8650 MARTIN WAY E STE 207
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6610
Practice Address - Country:US
Practice Address - Phone:360-951-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60689544225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist