Provider Demographics
NPI:1295258978
Name:FULLMER, ELSIE (MA, MS, RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:ELSIE
Middle Name:
Last Name:FULLMER
Suffix:
Gender:
Credentials:MA, MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10389 KALANG ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-8028
Mailing Address - Country:US
Mailing Address - Phone:725-256-9689
Mailing Address - Fax:
Practice Address - Street 1:10389 KALANG ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-8028
Practice Address - Country:US
Practice Address - Phone:725-256-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered