Provider Demographics
NPI:1649371022
Name:FULLER, KATHRYN AIMEE (RN, CFNP)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:AIMEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:RN, CFNP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:AIMEE
Other - Last Name:ERB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CFNP
Mailing Address - Street 1:1370 ROSECRANS ST
Mailing Address - Street 2:STE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2638
Mailing Address - Country:US
Mailing Address - Phone:619-223-2668
Mailing Address - Fax:619-223-2698
Practice Address - Street 1:1370 ROSECRANS ST
Practice Address - Street 2:STE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2638
Practice Address - Country:US
Practice Address - Phone:619-223-2668
Practice Address - Fax:619-223-2698
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11440363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11440OtherCAL. LICENSE NUMBER
CAP19565Medicare UPIN