Provider Demographics
NPI:1821690256
Name:FULLER, KARISSA (MS, RD, LND)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS, RD, LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 CALLE CESAR GONZALEZ APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1ER PISO, CENTRO MEDICO DE PUERTO RICO
Practice Address - Street 2:EDIF. DECANATO DE ESTUDIANTES
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-773-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2108133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered