Provider Demographics
NPI:1962828525
Name:FULLERTON, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:FULLERTON
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 1:18560 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-2148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18560 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-2148
Practice Address - Country:US
Practice Address - Phone:206-393-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60374379163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse