Provider Demographics
NPI:1659304384
Name:FULMER, KONDRA MIA
Entity Type:Individual
Prefix:MS
First Name:KONDRA
Middle Name:MIA
Last Name:FULMER
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 1:975 N SELOMONS ISLAND
Mailing Address - Street 2:PO BOX 980
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678
Mailing Address - Country:US
Mailing Address - Phone:410-535-5400
Mailing Address - Fax:410-414-9413
Practice Address - Street 1:975 N SELOMONS ISLAND
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678
Practice Address - Country:US
Practice Address - Phone:410-535-5400
Practice Address - Fax:410-414-9413
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2175101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health