Provider Demographics
NPI:1689638371
Name:FULLER, KATHLEEN MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:300 CONGRESS ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0907
Mailing Address - Country:US
Mailing Address - Phone:617-471-1161
Mailing Address - Fax:617-376-0435
Practice Address - Street 1:300 CONGRESS ST
Practice Address - Street 2:SUITE 102
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0907
Practice Address - Country:US
Practice Address - Phone:617-479-6636
Practice Address - Fax:617-376-0435
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2297885363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2297885OtherNURSE PRACTITIONER LICENSE