Provider Demographics
NPI:1578680633
Name:FULLER, LORI KIM
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:KIM
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2262 COUNTY ROAD 3007
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-1304
Mailing Address - Country:US
Mailing Address - Phone:918-336-6616
Mailing Address - Fax:
Practice Address - Street 1:2262 COUNTY ROAD 3007
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-1304
Practice Address - Country:US
Practice Address - Phone:918-336-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities