Provider Demographics
NPI:1699813899
Name:FULLER, KENDA SUE (PT)
Entity Type:Individual
Prefix:
First Name:KENDA
Middle Name:SUE
Last Name:FULLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 E ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80111-1731
Mailing Address - Country:US
Mailing Address - Phone:303-850-7717
Mailing Address - Fax:303-850-7517
Practice Address - Street 1:7120 E ORCHARD RD
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80111-1731
Practice Address - Country:US
Practice Address - Phone:303-850-7717
Practice Address - Fax:303-850-7517
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCP3793Medicare ID - Type Unspecified