Provider Demographics
NPI:1528604543
Name:FULLARD, KRISTY LEANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LEANN
Last Name:FULLARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4995
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4995
Mailing Address - Country:US
Mailing Address - Phone:209-581-5359
Mailing Address - Fax:
Practice Address - Street 1:2012 KENDALL AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3280
Practice Address - Country:US
Practice Address - Phone:209-581-5359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF12190864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily