Provider Demographics
NPI:1457736944
Name:FULLER, MISTINIQUE J (RN, LMP)
Entity Type:Individual
Prefix:
First Name:MISTINIQUE
Middle Name:J
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN, LMP
Other - Prefix:MRS
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, LMP
Mailing Address - Street 1:1968 W MUSE RD
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-9757
Mailing Address - Country:US
Mailing Address - Phone:509-770-4067
Mailing Address - Fax:
Practice Address - Street 1:1100 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1587
Practice Address - Country:US
Practice Address - Phone:509-770-4067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-25
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60154916163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)