Provider Demographics
NPI:1750047569
Name:FULLER, KIMBERLY S
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:FULLER
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 1:3030 30TH ST SE APT 213
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-1657
Mailing Address - Country:US
Mailing Address - Phone:202-594-9411
Mailing Address - Fax:
Practice Address - Street 1:3030 30TH ST SE APT 213
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-1657
Practice Address - Country:US
Practice Address - Phone:202-594-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant