Provider Demographics
NPI:1861043325
Name:FULLER, DEANNA LILA
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:LILA
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 1:21417 122ND PLACE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031
Mailing Address - Country:US
Mailing Address - Phone:253-639-0094
Mailing Address - Fax:253-639-0094
Practice Address - Street 1:21417 122ND PLACE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031
Practice Address - Country:US
Practice Address - Phone:253-639-0094
Practice Address - Fax:253-639-0094
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider