Provider Demographics
NPI:1265725006
Name:FULLER, KENDRA
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
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 1:850 BRODERICK ST
Mailing Address - Street 2:TENANT SERVICES
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-4498
Mailing Address - Country:US
Mailing Address - Phone:415-735-2700
Mailing Address - Fax:
Practice Address - Street 1:850 BRODERICK ST
Practice Address - Street 2:TENANT SERVICES
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-4498
Practice Address - Country:US
Practice Address - Phone:415-735-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942507835Medicaid
CA1720385032Medicaid