Provider Demographics
NPI:1215714126
Name:FULLER, KRISTEN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 PAUL ODOM RD
Mailing Address - Street 2:
Mailing Address - City:HAYNESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71038-6534
Mailing Address - Country:US
Mailing Address - Phone:504-912-6352
Mailing Address - Fax:
Practice Address - Street 1:505 HERRINGTON DR
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-2205
Practice Address - Country:US
Practice Address - Phone:318-539-5663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4336235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist