Provider Demographics
NPI:1528198306
Name:FULLER, KIMBERLY ANNE (LMT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
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 1:1217 NE BURNSIDE RD STE 502
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5770
Mailing Address - Country:US
Mailing Address - Phone:503-492-9310
Mailing Address - Fax:503-492-3905
Practice Address - Street 1:1217 NE BURNSIDE RD STE 502
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5770
Practice Address - Country:US
Practice Address - Phone:503-492-3910
Practice Address - Fax:503-492-3905
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist