Provider Demographics
NPI:1700865029
Name:FULLER, KRISTI H (PHD, ABPP-CN)
Entity Type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:H
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD, ABPP-CN
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 92303
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99509-2303
Mailing Address - Country:US
Mailing Address - Phone:907-561-0552
Mailing Address - Fax:907-561-0562
Practice Address - Street 1:2600 DENALI ST
Practice Address - Street 2:SUITE 450
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2746
Practice Address - Country:US
Practice Address - Phone:907-561-0552
Practice Address - Fax:907-561-0562
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK436103G00000X, 103T00000X, 103TA0700X, 103TB0200X, 103TC2200X, 103TC0700X, 103TF0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK436OtherSTATE LICENSE
AK203902391OtherTRIWEST
AK5093431OtherAETNA PIN
DC51470OtherNATIONAL REGISTER-PSYCHOL
AK5905OtherABPP-CN
AKPS8574Medicaid
AK5093431OtherAETNA PIN