Provider Demographics
NPI:1801319876
Name:GOODWIN-FULLER, KRISTY LOVE
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:LOVE
Last Name:GOODWIN-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 1:118 SINCLAIR LN
Mailing Address - Street 2:
Mailing Address - City:GLOSTER
Mailing Address - State:LA
Mailing Address - Zip Code:71030-3028
Mailing Address - Country:US
Mailing Address - Phone:318-933-8422
Mailing Address - Fax:318-933-8415
Practice Address - Street 1:118 SINCLAIR LN
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:LA
Practice Address - Zip Code:71030-3028
Practice Address - Country:US
Practice Address - Phone:318-933-8422
Practice Address - Fax:318-933-8415
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA82-1289809OtherINTERNAL REVENUE