Provider Demographics
NPI:1639418494
Name:FULLER, STEPHANIE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
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 7600
Mailing Address - Street 2:3515 BROADWAY AVE.
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-7600
Mailing Address - Country:US
Mailing Address - Phone:605-668-3100
Mailing Address - Fax:605-668-3460
Practice Address - Street 1:3515 BROADWAY AVE.
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-7600
Practice Address - Country:US
Practice Address - Phone:605-668-3100
Practice Address - Fax:605-668-3460
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist